Boore, Caroline

A FRAMEWORK FOR E-HEALTH IMPLEMENTATION IN THE
HEALTH CARE SECTOR IN KENYA: A GROUNDED THEORY
APPROACH
CAROLINE BOORE
A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE AWARD OF DEGREE OF DOCTOR OF
PHILOSOPHY IN BUSINESS ADMINISTRATION, SCHOOL OF
BUSINESS, UNIVERSITY OF NAIROBI
2018
DECLARATION
I, the undersigned, declare that this Thesis is my original work and has not been submitted to
any other college, institution or university other than the University of Nairobi for academic
credit.
Signature …………………………………… Date…………………………….

Caroline Boore
D80/72843/2012
Department of Management Science
School of Business
University of Nairobi
This thesis has been submitted with our approval as university supervisors
Signature…………………………………….. Date…………………………….
Prof James Njihia
School of Business
Signature……………………………………… Date……………………………..
Dr. X.N Iraki
School of Business
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ACKNOWLEDGEMENT
I thank and honor God, The Almighty, for bringing me to this world and for taking me
through my entire educational career and helping me to complete this dissertation.
I am deeply indebted to my supervisors, Prof Njihia and Dr Iraki. Thank you for your
support, guidance and advice. You provided me with constant, constructive supervision,
underpinned by understanding, and patience especially with the distractions of the life
demands. You made this journey productive, enlightening yet enjoyable. Thanks for
believing in me.
To the participants involved in the study, thank you for your honest responses and the desire
to be involved in the study. You constantly encouraged me to continue with the enthusiasm
you showed for better healthcare delivery.
To my classmates Dr Gabriel Kamau and Dr Daniel Muendo whom I have always turned to
in the most difficult moments, I say thank you. And to all those other colleagues and friends
who have in diverse ways contributed to the making of this program I say thank you and
May Almighty God bless each one of you mightily.
Finally, I would like to thank and appreciate my family who were the anchor of strength
even when the tide was really rough and I felt like throwing in the towel. Thank you so
much for your constant encouragement and unwavering support. The journey would have
been much rougher without you.
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DEDICATION
This thesis is dedicated to my dad who passed on during the process of completing the
study. “Dad, you always reminded me that growth happens in the valleys as well, so never
give up and there lay my strength to hold on. Am forever grateful.”
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TABLE OF CONTENT
DECLARATION ................................................................................................................ii
ACKNOWLEDGEMENT .................................................................................................iii
DEDICATION ....................................................................................................................iv
LIST OF TABLES .............................................................................................................xi
LIST OF FIGURES ...........................................................................................................xii
ABSTRACT ........................................................................................................................ xvi
CHAPTER ONE: INTRODUCTION ..............................................................................1
1.1 Background of the Study ................................................................................................ 1
1.1.1 Strategic Issues in E-health Implementation ......................................................... 3
1.1.2 Healthcare Sector in Kenya ...................................................................................6
1.2 Research Problem ...........................................................................................................10
1.3 Objective of the Study ....................................................................................................13
1.4 Value of the Study ..........................................................................................................13
1.5 Thesis Outline ................................................................................................................14
1.6 Chapter Summary ...........................................................................................................15
CHAPTER TWO: LITERATURE REVIEW .................................................................16
2.1 Introduction ....................................................................................................................16
2.2 Definitions of e-health ....................................................................................................16
2.2.1 Forms of e-health ..................................................................................................19
2.3 Issues in E-health Implementation .................................................................................21
2.3.1 ICT and Health Policies ........................................................................................ 21
2.3.2 E-legislation ..........................................................................................................23

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2.3.3 E-Health Standards ................................................................................................ 25
2.3.4 E-Health Infrastructure .......................................................................................... 27
2.3.5 ICT Competence ...................................................................................................30
2.4 E-health Frameworks .....................................................................................................31
2.5 Theories of E-Health Implementation ............................................................................34
2.5.1 Technology Organization Environment Model (TOE) .........................................34
2.5.2 Actor Network Theory (ANT) ..............................................................................36
2.5.3 Grounded Theory (GT) ......................................................................................... 39
2.5.3.1 Differences between Glaserian Version and Straussian Version.............43
2.5.3.2 Criteria for Evaluating Quality of GT Research Process ......................... 45
2.6 Empirical Studies on Strategic E-Health Issues ............................................................. 47
2.6.1 Summary of Literature Review and Research Gaps .............................................49
2.7 Research Approach ........................................................................................................52
2.8 Chapter Summary ...........................................................................................................54
CHAPTER THREE: RESEARCH METHODOLOGY .................................................55
3.1 Introduction ....................................................................................................................55
3.2 Research Paradigm .........................................................................................................55
3.2.1 Positivist Paradigm ................................................................................................ 58
3.2.2 Interpretive Paradigm ............................................................................................ 58
3.2.3 Pragmatism Paradigm ........................................................................................... 59
3.2.4 Grounded Theory and Pragmatism .......................................................................61
3.3 Research Design .............................................................................................................65
3.3.1 Qualitative Approach ............................................................................................ 65
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3.3.2 Quantitative Approach .......................................................................................... 67
3.3.3 Grounded Theory Methodology ............................................................................68
3.4 Population and Sampling .............................................................................................. 71
3.5 Data Collection ...............................................................................................................73
3.6 Reliability ....................................................................................................................... 75
3.7 Validity ........................................................................................................................... 75
3.8 Data Analysis ................................................................................................................77
3.9 Ethical Considerations....................................................................................................79
3.10 Chapter Summary .........................................................................................................80
CHAPTER FOUR: DATA ANALYSIS AND INTERPRETATION ............................ 81
4.1 Introduction ....................................................................................................................81
4.2 The Data Analysis Process ............................................................................................. 81
4.2.1 Open Coding .........................................................................................................84
4.2.2 Writing Memos .....................................................................................................95
4.2.3 Axial Coding .........................................................................................................96
4.2.4 Selective Coding ...................................................................................................99
4.3 Quality of e-health Systems ........................................................................................... 102
4.4 Benefits of e-health Systems .......................................................................................... 106
4.5 Macro Political Environment ......................................................................................... 112
4.6 Socio Cultural Environment ........................................................................................... 120
4.7 Online Safety and Security ............................................................................................. 128
4.8 Technological Environment ........................................................................................... 134
4.9 Change Process Management ......................................................................................... 141
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4.10 Systems Integration ......................................................................................................147
4.11 Organizational Efficiency ............................................................................................ 152
4.12 Legal Environment .......................................................................................................163
4.13 Socioeconomic Environment ....................................................................................... 168
4.14 ICT Competence Environment.....................................................................................173
4.15 E-Standards Environment ............................................................................................ 178
4.16 Chapter Summary .........................................................................................................183
CHAPTER FIVE: DISCUSSIONS ...................................................................................184
5.1 Introduction ....................................................................................................................184
5.2 Factors that affect the Successful Implementation of e-health Systems ........................ 184
5.2.1 Quality of e-health System as a Determinant for the Success of e-health ............184
5.2.2 Sociocultural Environment as a Determinant for the Success e- health...............185
5.2.3 Online Safety and Security as a Determinant for the Success of e-health ............187
5.2.4 Technological Environment as a Determinant for the Success of e-health...........188
5.2.5 Macro Political Environment as a Determinant for the Success e-health .............190
5.2.6 Change Process Management as a Determinant for the Success of e-health ........192
5.2.7 Systems Integration as a Determinant for the Success of e-health........................ 193
5.2.8 Organisational Efficiency as a Determinant for the Success of e-health ..............194
5.2.9 Socioeconomic Environment as a Determinant for the Success of e-health .........196
5.2.10 Legal Environment as a Determinant for the Success of e-health ...................... 197
5.2.11 Benefits of e-health Systems ...............................................................................199
5.2.12 ICT Competence as a Determinant for the Success of e-health .......................... 199
5.2.13 E-standards as a Determinant for the Success of e-health...................................200
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5.3 Interrelationships between the Core Category (implementation of e-health systems)
and other Categories .......................................................................................................202
5.4 Final Categories ..............................................................................................................211
5.4.1 Managerial Practices ............................................................................................. 211
5.4.2 IS Capability ..........................................................................................................214
5.4.3 Political e-readiness............................................................................................... 217
5.4.4 Societal e-readiness .............................................................................................. 220
5.4.5 Regulatory Framework .......................................................................................... 223
5.5 The Final Conceptual Model .......................................................................................... 226
5.6 Comparison of the New Framework with other Existing Frameworks ......................... 229
CHAPTER SIX: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS ......231
6.1 Introduction ....................................................................................................................231
6.2 Summary of Findings .....................................................................................................231
6.3 Conclusion ...................................................................................................................... 234
6.4 Implications of the Study ............................................................................................... 237
6.4.1 Theoretical Contribution ......................................................................................... 238
6.4.2 Contribution to Knowledge ....................................................................................238
6.4.3 Methodological Contribution..................................................................................239
6.4.4 Contribution to Policy............................................................................................. 239
6.4.5 Contribution to Practice .......................................................................................... 240
6.5 Recommendations ..........................................................................................................240
6.6 Limitations of the Study .................................................................................................241
6.7 Suggestions for Further Study ........................................................................................ 241
6.8 Chapter Summary ...........................................................................................................242
REFERENCES ...................................................................................................................243
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APPENDICES ....................................................................................................................257
Appendix 1 : Interview Guide .....................................................................................257
Appendix II: Samples of interviews scripts ..................................................................260
Appendix III: Memos....................................................................................................262
Appendix IV: Grounded Theory Methodology ............................................................ 270
Appendix V: Letter of invitation for the interview ....................................................... 271
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LIST OF TABLES
Table 2.1: Differences between Glaserian and Straussian Versions ...................................... 43
Table 2.2: Criteria for Evaluating Quality of Grounded Theory Research Process ............... 46
Table 2.3: Summary of Research Gaps .................................................................................. 50
Table 4.1: Quality of e-health Systems .................................................................................. 86
Table 4.2: Process Summary of Key Points, Incidents and Codes for the Quality of
e-Health Systems .................................................................................................. 88
Table 4.3: Diagrammatically the Emergence of the Quality of e-health Systems
Category ............................................................................................................... 89
Table 4.4: Emergent Categories and their Properties ............................................................. 93
Table 4.5: Occurrences arising for the Quality of e-health Systems ...................................... 98
Table 4.6: Changes made to the Initial Categories ................................................................. 99
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LIST OF FIGURES
Figure 2.1: Research Approach (adapted from Charmaz, 2013) ............................................ 53
Figure 4.1: Word Tree on Quality of e-health Systems ......................................................... 91
Figure 4.2: Diagrammatical Emergence of the Quality of e-health Systems Category ......... 92
Figure 4.3: Quality of e-health Systems Category has an influence on the
Implementation of e-health systems .................................................................. 103
Figure 4.4: Benefits of e-health Systems has an influence on the Users Perception
about e-health Systems thus on the Implementation of the Systems ................ 107
Figure 4.5: Macro Political Environment Category has an influence on the
Implementation of e-health Systems .................................................................. 112
Figure 4.6: Social Cultural Environment Category has an influence on the
Figure 4.7 Online safety and Security Category has an influence on the Implementation
of e-health Systems ............................................................................................ 129
Figure 4.8: Technological Environment Category has an influence on the
Figure 4.9: Change Process Management Category has an influence on the
Figure 4.10: System Integration Category has an influence on the Implementation of
e-Health Systems ................................................................................................ 148
Figure 4.11: Organisational Efficiency Category has an influence on the Implementation
Figure 4.12: Legal Environment Category has an influence on the Implementation of
e-health Systems ................................................................................................. 164
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Figure 4.13: Social Economic Environment Category has an influence on the
Figure 4.14: ICT Competence Environment Category has an influence on the
Figure 4.15: E-standards Environment Category has an influence on the Implementation
Figure 5.1: Interrelationships between Categories ............................................................... 203
Figure 5.2: Managerial practices, and their associated attributes that are likely to affect
the implementation of e-health systems ............................................................. 213
Figure 5.3: IS Capability, and their attributes that are likely to affect the implementation
of e-health systems ............................................................................................. 216
Figure 5.4: Political e-readiness, and their associated attributes that are likely to affect
the implementation of e-health systems ............................................................. 219
Figure 5.5: Societal e-readiness, and their associated Concepts that are likely to Affect
the Implementation of e-Health Systems ........................................................... 222
Figure 5.6: Regulatory Framework, and their Associated Attributes that are likely to
affect the Implementation of e-health Systems .................................................. 224
Figure 5.7: Concept Diagrams showing the Emergence of the Five Main Themes from
the Thirteen Sub categories ................................................................................ 225
Figure 5.8: Final Framework of the factors that affect implementation of e-health
systems that is grounded from data .................................................................... 228
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ABBREVIATION AND ACRONYMS
AU African Union
ANT Actor Network Theory
CHI Consumer Health Informatics
DOI Diffusion of Innovation
DHIS District Health Information Software
EMR Electronic Medical Record
E-health Electronic Health
EHR Electronic Health Record
EHI Electronic Health Information
ET Emergence Theory
EU European Union
EPSOS European Patient Smart Open Systems
GT Grounded Theory
GTM Grounded Theory Methodology
GDP Gross Domestic Product
HIS Health Information Systems
HKM Health Knowledge Management
HMIS Health Management Information Systems
ICT Information Communication & Technology
IS Information System
ISD Information System Development
IPPD Integrated Payroll and Personnel Database
ISMS Information Security Management System
xiv
IFMIS Integrated Financial Management Information System
IT Information Technology
ITU International Telecommunication Union
KCAA Kenya Communications Act
MDG Millennium Development Goals
MOH Ministry of Health
MPESA Mobile Pesa
NGO Non-Governmental Organization
OSI Open Systems Interconnection
PC Personal Computer
SDG Sustainable Development Goal
TOE Technology Organization Environment
USA United States of America
WHO World Health Organization
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ABSTRACT
Information and Communication Technology (ICT) has turned into a key enabling tool in
the enhanced healthcare delivery and has impacted how we live and see the world. The
implementation of Information Technology (IT) and particularly e-health is, seen as a
potential tool in enhancing healthcare delivery. The purpose of this thesis was to develop a
holistic framework that addresses e-health implementation in developing countries. The
existing frameworks for e-health implementation in developing countries are not holistic and
only address few aspects of e-health implementation. Basically the frameworks that are in
place may not work in the context for many developing countries for the implementation of
e-health systems. Moreover the frameworks have also been developed mainly using
secondary data. In addition they have been developed based on positivist approach that
forces certain preconceptions unlike grounded theory approach that allows for theory to
emerge from data. The inadequacy of the existing frameworks necessitated a different
approach towards healthcare research. Thus there was a case for developing a holistic
framework that is grounded from empirical data. This was addressed by using grounded
theory approach to develop a data driven framework for implementation of e-health systems
in the healthcare sector in Kenya. The study used a paradigmatic stance of pragmatism and
grounded theory methodology. Theoretical sampling was used to interview a total number of
30 respondents. NVivo software version 11 was used for the analysis of the data. The data
analysis was done using three levels of coding namely open, axial and selective. Thirteen
categories emerged from the three stages of coding. The thirteen categories were further
combined to form five main categories. The findings of the study generated a data driven
framework that explains implementation of e-health in Kenya consisting of five categories
namely political e-readiness, managerial practices, IS Capability, societal e-readiness and
regulatory framework. The implications of the study were that it developed a data driven
theory rather than testing theory. The theory presented was done from theory building
approach with a pragmatism paradigm. This is a major departure from the common practise
of theory testing and surveys in IS research. Therefore this can be used as a point of
reference for Kenyan researchers that may wish to utilise theory building approach. The
theory developed is a substantive theory for e-health implementation which can be in future
developed into a formal theory. In addition for developing countries such an approach would
be preferable due to the complex context and nature of problems. A reductionist approach
cannot effectively address such complex contexts. The model is holistic and presents
categories that the Government may find helpful in addressing the e-health implementation
challenges as well as improve on the national e-health strategy. Similarly the IS
professionals can use the findings to improve their professional practise in healthcare
research. In conclusion the study generated three other new themes not addressed in the
existing frameworks. Thus there is a need to change focus from the current technological
bias in e-health implementation and address other non technological issues.
xvi
CHAPTER ONE
INTRODUCTION
1.1 Background of the Study
Presently the rates of implementation of Information and Communication Technology (ICT)
have become important pointers to economic development. Several developing countries
have put technological innovation on top of their national growth agenda and invested
greatly into ICT. For example in the healthcare sector the application of ICT commonly
referred to as E-health is discerned as the main driving power in the unfolding healthcare
reforms in many developed and developing countries. E-Health apparently seems to provide
a remedy for expediting the required transformation for healthcare sector (Korpela, 2012 &
Kiura, 2012). According to Eysenbach (2007) e-Health is the utilization of ICT, particularly
the Internet, to enhance superior healthcare management. E-Health consists of applications
that boost disease prevention, timely patient diagnosis, and enhanced patient management.
Primarily these applications include electronic Medical Records (EMRs), Telemedicine,
Health Knowledge Management, Consumer Health Informatics (CHI), M-Health and
Healthcare Information Systems (HIS). WHO (2013) observed that the utilization of ICT
applications in healthcare is merely not just about innovation, but rather a means to attain a
progression of better outcomes, for instance, health workers settling on superior treatment
choices and doctor's facilitated to give higher quality and more secure care.
The healthcare environment is intricate and multifaceted thus to fully understand it
conceptually required grappling with many intertwined and overlapping strategic issues.
Such issues among others include: e-Health standards; ICT and health policies; e-legislation;
e-Health infrastructure; ICT competence (Mugo, 2014; Korpela, 2013; Lazaro, 2013; Juma
et al., 2012; Mbarika, 2011). There are several frameworks that exist for e-health
1
implementation but none have captured the essence of e-health implementation in
developing countries. The existing frameworks are not holistic and only address few aspects
of e-health implementation. Basically they mainly focus on implementation from a
technological deterministic perspective while silent on other non- technological perspective
(Braa, 2007, Xiangzhu et al., 2013; Fanta, 2015). Similarly the frameworks that are in place
may not show the real context for many developing countries for the implementation of e-
health systems. Moreover the frameworks have also been developed mainly using secondary
data. There was need for developing a holistic framework that is grounded from empirical
data (Korpela, 2013). Therefore this study was data driven aimed at developing a holistic
framework for e-health implementation using Grounded Theory approach.
Theories of information systems such as Technology Organization Environment Model and
Actor Network Theory are used to explain IS research in healthcare (Braa, 2007). However
they possess certain limitations as they force a certain preconceptions unlike Grounded
Theory (GT) approach that was adopted for this study. In contrast GT allows open
exploration depicting development of concepts and showing their relationships thereby
coming up with a substantive theory that may better elucidate the phenomenon (Charmaz
2014). GT is generally offered as an inductive approach. It allows the researcher to develop
theories right from the raw data. The data collection and analysis is done logically to keep
the data grounded without forcing it to fit with current theories (Glaser and Strauss, 1967;
Fernández & Lehnmanm, 2005).
The healthcare sector in Kenya is transiting towards a new paradigm shift where services are
now devolved to the counties. Thus this requires new ways of thinking and managing the
sector to enhance service delivery. The health care sector in Kenya is documented as having
trailed behind other industries, for example the financial sector, in the usage and
2
implementation of innovative information technologies (Juma et al., 2012). According to
WHO (2013), the sector has several hurdles, amongst them the ever-increasing cost, an
elderly population and demand for superiority healthcare services. This therefore requires
the healthcare sector to urgently find and implement solutions to effectively improve
healthcare delivery. This can be realized by putting in place strategies and incorporate ICT
in delivery of healthcare service for improved results. E-Health is a worldwide ideal method
in transforming the healthcare sector in regard to improved delivery of services and better
outcomes for long term benefits and sustainability (Xiangzhu et al., 2013). Thus there was
need for a strategic approach for e-health and its implementation in Kenya which was the
primary motivation for this study.
1.1.1 Strategic Issues in E-health Implementation
Literature review on e-health implementation is quite immense but the most strategic
concerns addressed in the articles are recognized as falling into five significant areas.
Namely: e-Health standards; ICT and health policies; e-legislation; e-Health infrastructure;
ICT competence (Xiangzhu et al., 2013; Mugo, 2014; Lazaro, 2013; Juma et al., 2012;
Korpela, 2013; Murray, 2010; Mbarika, 2011; Oladosu, 2009b ; Braa, 2007; Jennet &
Siedlecki, 2001).
The first concern that is dominant to e-health implementation is ICT and e-health policies. A
policy is defined as “a set of statements, directives, regulations, laws and judicial
interpretations that direct and manage the life cycle of e-health” (Murray, 2010, p.3).
According to the WHO, (2011) policies in an organization help in developing a vision for
the future. They act as reference for short, medium and long-term objectives. In addition
they guide in setting out priorities, delegating roles and defining action to be taken in the
3
organisation. Policy and decision producers in the larger healthcare system should view e-
health as a key player in provision of improved health service. In Kenya for example the
government in corroboration with the private sector has made vital steps towards ways and
techniques for the up take of e-health. For instance the Strategic Plan for Health Information
Systems (HIS) (2009-2014) and the Kenya ICT policy (2006).
E-Legislation is a key concern for the attainment of e-health. The integration of ICT in
healthcare service provision brings the difference between the traditional face-to-face
healthcare delivery and the e-health. Many e-health articles have suggested the necessity to
come up with policies on standards and security in delivery of healthcare but developing
countries have given less attention to confidentiality, standards, and security (Mugo, 2014;
Xiangzhu et al.,2013; Treurnicht, 2009). Insufficient electronic legislation for instance has
adversely affected e-Health implementation in Kenya (Juma, 2012). The Kenya
Communications (Amendment) Act, 2009 for instance does not address all facets of e-
transactions, such as confidentiality of data and ethics in e-health.
Standard policies are crucial in achieving interoperability in order to share information.
However, the e-health standard area is burdened with difficulties arising from the vast
numbers of current standards, some of them contending and overlapping, while some even
contradicting each other (Juma, 2012; Mbarika, 2011). Typically a standard is a set out
guideline agreed upon and appropriate way of doing things. According to Braa, (2007) a
standard could be formal, proprietary or open. Notwithstanding, satisfactory standards for
medical imaging, interoperability, programming, communication framework design,
therapeutic informatics, and bioinformatics are yet to be established in developing countries
4
(Juma et al., 2012; Braa, 2007). Indeed the ISO 27001 standard frequently referred to as
Information Security Management System (ISMS) does not address the e-health privacy
issues. On the other hand Kenya for example has made unlimited efforts towards
developing e-health standards with the publication of the Standards and Guidelines for
Electronic Medical Records (EMR) in Kenya (2010). However the standards do not address
Medical record portability, privacy and ownership which are key concerns for e-health
implementation (Juma et al., 2012).
By and large a country requires a firm ICT platform to support e-health implementation
(Mbarika, 2004). As indicated by WHO (2013) an ICT platform is a physical arrangement of
broadcast communications pathways and associations that transmit voice, video and
information including a web of media communications, data and computing technology.
Lazaro et al., (2013) refers to the internet as the interconnection of a number of networks
utilizing a standard packet switching protocol for communications. The lack of
telecommunication infrastructure in developing countries poses a big challenge in transfer of
e-health. In many of the developing countries, implementing healthcare information
technology based solutions becomes a challenge due to insufficient funding, inadequate
resources and weak health care infrastructure platform (Qureshi et al., 2013; Jennett et al.,
2001). In the last decade, Kenya has experienced significant growth in ICT infrastructure
(National Broadband Strategy, 2013). Indeed since 2000, the sector has outpaced all others
in the Kenyan economy, growing on average by approximately 20% annually (World Bank
Economic Update, 2014).
5
Lack of computer training among healthcare workers is cited as an important determinant of
e-health implementation (Mbarika, 2011). Mishra (2007) emphasizes that computer training
are essential to sustain positive attitudes about electronic clinical data which translates to
better reception and implementation of e-health. Kiura (2012) relates low usage of e-Health
in many developing nations to absence of computer competence among the clinical workers.
In nations that have upheld computer training for clinical workers, appreciation of e-Health
and real utilization is generally high (Korpela, 2013; Mbarika, 2012). Training improves
mindfulness and certainty level as users can overcome technophobia while relating usage to
expected advantages (Kimaro, 2005). Additionally Lazaro et al. (2013) suggests that ideal
utilization of IT towards the transformation of healthcare services requires IT know-how
among the healthcare workers. The relationship between computer skills and usage of e-
Health is likewise discussed by Juma et. al. (2012) who emphasizes that deficient IT
competence in the healthcare sector in Kenya clarifies the little implementation of e-Health.
In addition without reasonable IT competence, user participation in decision and
advancement of the innovation ends up plainly troublesome which may prompt having e-
Health advances that are not comprehensively acknowledged or utilized satisfactorily
(Murray, 2010 and Kaye, 2010).
1.1.2 Healthcare Sector in Kenya
The healthcare sector encompasses the public healthcare system, with the main group being
the Ministry of Health and government parastatal organizations. The private healthcare
sector includes private for-profit, NGO, and faith based facilities. Generally the healthcare
services are delivered through a network of over 4,700 health facilities countrywide, with
the public health sector system accounting for about 51 percent of these facilities (Ministry
of Health, 2013).
6
Currently the public healthcare sector is one of the devolved functions in the constitution.
The sector comprises of the accompanying levels of health offices: national referral
hospitals (level 6), county hospitals (level 5), sub-county hospitals (level 4), health centres
(level 3), and dispensaries (level 2). National referral hospitals (level 6) are at the top of the
health care system, giving those services that are not available in other levels due to lack of
enough expertise. The two national referral hospitals are Kenyatta National Hospital in
Nairobi and Moi Referral and Teaching Hospital in Eldoret (Ministry of Health, 2013).
County hospitals (level 5) act as referral hospitals at the county level while sub county
hospitals (level 4) focus on the conveyance of healthcare services at sub county level. The
network of health centres (level 3) provides many of the ambulatory health services. They
generally offer preventive and curative services, generally tailored to meet the local needs of
the people. Dispensaries (level 2) are intended to be the framework's first level of contact
with patients, at the ward level. The government healthcare service is supplemented by
private owned hospitals, private owned healthcare centres and religious based hospitals,
which collectively give between 30 and 40 percent of the hospitals beds in Kenya (Ministry
of Health, 2013).
The health care sector is facing numerous challenges, among them high disease burden of
both communicable and non-communicable diseases, rising cost of healthcare, an elderly
population and demand for excellent healthcare services (WHO, 2013). In addition there is
a prolonged shortage of medical personnel. Like most countries in Africa, the scarcity of
healthcare workers is a major problem in Kenya. WHO mentioned Kenya as a country with
less healthcare workers as compared to the set minimum threshold of 23 doctors, nurses and
midwives per population of 10,000 for quality and effective service delivery (WHO, 2013).
7
Kenya’s most recent ratio stands at 1 per 26, 438 (Ministry of Health, 2013). This shortage
is markedly worse in the rural areas where, as noted in a study by Transparency
International (2012), under-staffing levels of between 50 and 80 percent were documented at
county and rural health facilities. This therefore calls for an urgent need to work on
strategies that will improve healthcare delivery. This can be achieved by harnessing ICT to
close the healthcare service delivery.
Financial services are predominantly well represented with regards to computerisation of
procedures using ICT. Kenya is said to have an upper hand in financial service delivery. A
good example is the M-PESA mobile money transfer, which has successfully seen 20
million Kenyans benefit with the service via a mobile phone particularly to the unbanked.
The IPPD system provides accurate and consistent personnel data in the Public Service
while the IFMIS system enhances efficiency in planning, budgeting, procurement,
expenditure management and reporting in the National and County Governments in Kenya
(Mugo et al., 2014). By contrast, Kenya’s healthcare players have not embraced technology
to improve their service delivery. The Kenyan healthcare system has had challenges
especially in handling the rising cost and the high demand for excellent health care services.
This is in the midst of the shortage of skilled health care professional despite the fact that it
was allocated KSh 60.3bn in 2016/17 to enhance access and quality of health services. Over
the three years, government financing as a percentage of GDP has been consistent at slightly
above four percent which is considered low according to the recommendation of African
Union (National Treasury, 2016). In April 2001, the countries that are members of the
African Union met and vowed to set a target of allocating at least 15% of their yearly budget
8
to enhance the healthcare sector. Years later, only one African country reached this target.
Twenty-six countries had increased the percentage of government expenses allocated to
health and 11 had reduced it. In the remaining nine countries Kenya included, there was no
obvious trend up or down (WHO, 2013).
E-Health frameworks in Kenya are at their initial stages, though the prospective for its
growth is enormous (Juma et al., 2012 and Mugo et al., 2014). Thus Oladosu et al (2009)
and Mbarika et al. (2012) urge that attainable solutions need to be customized towards
existing success stories and local setting where the e-health is being established and that
systems such as e-health require contextual considerations in implementation and
sustainability. In contrast, developed countries like Canada and the Netherlands amongst
others have encompassed the utilization of information communications (ICT) applications
within the hospitals and health clinics. In this regard some of the examples of the utilization
of ICT applications in these health facilities include: automation of health records, electronic
preparation for appointments, telemedicine, usage of the Internet for the purposes of
communication and the use of magnetic cards (Eysenbach et al., 2007; Korpela, 2013).
This notwithstanding some electronic medical records systems have been moderately
implemented in Kenya such as level- 4, level -5 hospitals and the District Health
Information System (DHIS). DHIS is a health information system, whose primary purpose is
to expedite health data collection and reporting. DHIS does not automate vital business
processes at the health department administrative level, and work processes at health
facilities. The system does not capture essential health encounter information. Service
delivery and data collection are two separate activities. The DHIS does not handle all
aspects of a healthcare information system which includes scheduling and inventory
9
management of doctors and equipment, billing, electronic medical records, disease tracking,
reporting/auditing, regulatory compliance, and security access control (Ministry of health,
2013). Therefore there is need for a more comprehensive strategic level to e-health
implementation approach for developing countries like Kenya.
1.2 Research Problem
In the healthcare sector, increasing costs and new sorts of medical issues bring about ever
increasing weight on the healthcare frameworks, and kindle new ways for promoting access
and decreasing healthcare expense (Bhatia, 2014). Basically e-health frameworks symbolize
potential solutions for enhanced healthcare openness and quality, timely decision making,
containing costs, and providing enhanced excellence care. The need for effective e-health
implementation is inexorable and more so by the healthcare sector today especially in
developing countries. Although the hurdles faced in the implementation of these systems are
numerous, hospitals today are being forced into the implementation of information systems
for their continued existence. The existing frameworks for implementation of e-health
systems are vague, weak and fragmented. They neither address people centered nor
holistically contextual issues affecting the systems (Korpela, 2013).
The healthcare sector in Kenya is acknowledged as having trailed behind other industries,
for example the financial sector, in the usage and implementation of new information
technologies. The sector is characterized by many and fragmented applications which lack
data sharing mechanisms. Manual processes represent a substantial part of the processes.
These systems suffer from lack of data ownership, poor data quality, poor data security and
backup procedures and consequently rarely used for decision-making. Thus this poses
challenges when reporting what is really happening in the health care to support disease
10
surveillance, planning, clinician and strategic decision making (Juma et al., 2012; Kiura,
2012; Mugo et al. 2014). Presently there is no e-health framework that has been developed
using a theory building approach in Kenya. Hence there is need for a different approach
towards exploring implementation of e-health technologies in the healthcare sector.
Generally only a limited number of empirical studies have concentrated on e-health outside
developed countries. Various studies done on factors affecting implementation of e-health in
developing countries found out that the most repulsive challenges were lack of ICT
competence, e-health policies, e-infrastructure and resistance to change by healthcare
workers (Mbarika et al., 2012, 2011). Further to this Lazaro (2013) identified inadequate
infrastructure resources as a big barrier for e-health sustainability. Mugo et al. (2014) and
Treurnicht (2009) examined the factors that affect Electronic Medical Records
implementation. The study found that implementation of EMR is greatly influenced by
attitudes of healthcare workers and ICT competence. Moreover Xiangzhu et al. (2013) had
identified e-legislation as a big problem to EMR implementation. Juma et al. (2012)
examined the current status of e-health in Kenya and he cited e-standards and e-
infrastructure as the barriers to its success. These findings were in line with Braa’s (2007)
findings that e-standards are a prerequisite for implementation of e-health. Likewise Kaye,
(2010) examined the barriers to e-health sustainability and the findings were cited as lack of
ICT competence and cultural factors. Similarly Qureshi et al. (2013) sought to find out the e-
health drivers and challenges. The findings were in agreement with other researchers as they
included ICT competence and clinician resistance. Although Korpela (2013) suggested a
holistic approach to information system implementation in healthcare in Finland that
addresses the domains of both healthcare specialists and common citizens, it may not be
applicable in a developing country context like Kenya that is faced with a myriad of
challenges hence the need for a new framework.

11
These studies discussed above indicate that e-Health implementation in healthcare sector is a
crucial issue yet to be appropriately addressed. Most of the studies (Mugo et al., 2014;
Lazaro et al., 2013; Mbarika et al., 2012; Kaye, 2010; Kimaro, 2007) have focused on IT
implementation in healthcare that supports operational level decision making where e-health
is equated to information systems which support operational activities of the hospital. In this
case it is seen as a support rather than a component of the strategy realization process which
should constitute part of the national e-heath strategy. The review indicates that most of the
findings are addressed in discrete bits and pieces and there is no comprehensive approach
that is suggested on how these factors relate to one another to form one comprehensive
framework. The frameworks are not holistic and they just address few aspects of e-health
implementation. Moreover they focus on implementation from a technological deterministic
perspective while silent on other non- technological perspective (Braa, 2007, Xiangzhu et
al., 2013; Fanta, 2015). In addition the frameworks have also been developed mainly using
secondary data. Thus there was need for a primary data driven approach for an e-health
implementation framework suited to Kenya’s healthcare system that has been devolved in
the new constitution dispensation. Furthermore, the existing frameworks have been
developed based on positivist approach that forces certain preconceptions unlike grounded
theory approach that allows for theory to emerge from data.
It is against this background that the researcher was motivated to come up with a
comprehensive e-health framework that guides the process of its implementation in
developing countries and Kenya in particular. Therefore, this study sought to answer the
following research question. What are the factors that contribute to successful e-health
implementation in Kenya’s healthcare sector and how are they inter related?
12
1.3 Objective of the Study
To identify factors relevant to, and develop a model for e-health implementation framework
for Kenya’s healthcare sector.
1.4 Value of the Study
The study steps out of the traditional paradigms to Pragmatism. A framework was
developed that is grounded from primary data explaining the factors that are necessary for
the successful implementation of e-health systems in a developing country context. This can
be used by future scholars as the baseline of future studies in this field of study. This has
added into the work of Korpela (2013) and Braa (2007) frameworks on healthcare
information systems.
The findings of the study will assist information system professionals and consultants
improve on their professional practice especially in the area of healthcare research. These
professionals can use the findings of the study to enhance their understanding of the
healthcare sector.
The findings of the study will offer assistance to the Government of Kenya and developing
countries in identifying gaps that need to be filled so that successful implementation of e-
health systems in the country can be realised. This is supported by the fact that healthcare is
one of the most fundamental needs in developing countries such as Kenya thus its successful
implementation would go along way to benefit the citizens (Kiura, 2012).
The study will assist Ministry of Health and WHO in the effective e-Health policy
implementation, monitoring and evaluation. Research indicates that medical mistakes are a
substantial cause of mortality in developing countries. Generally such medical errors are not
13
due to incompetence of physician but rather the lack of infrastructure to support timely
decision making in treatment of patients. Alternatively e-health is one of the methodologies
that can be adopted to enhance the superiority of healthcare services (Anwar et al, 2012).
1.5 Thesis Outline
This thesis will have six chapters, with the following contents:
Chapter 1; Introduction: This chapter contains the introduction for the study and background
information. An introductory literature review of the healthcare sector and e-health in
particular is analysed. It is followed by the research problem, objectives and significance of
the study.
Chapter 2; Literature Review: This chapter evaluates the literature on e-health and the issues
that underlie its implementation performance in many parts of the world. Both theoretical
and empirical literatures are reviewed. From the review the gaps are identified to inform a
general model for the study.
Chapter 3; In this chapter the research philosophy, design, sampling procedure, target
population are discussed. Data collection procedure and data analysis and methods
undertaken to resolve the problem area are explained in detail.
Chapter 4; This chapter discusses data analysis, and interpretation. The review of the various
thematic analysis and categories from each unit of analysis are described showing a brief
overview of all categories in each unit of analysis. Each category is described with all its
attributes showing how it emerged.
14
Chapter 5; This chapter offers discussions about the phenomenon being studied and the final
framework that is grounded from data. The framework explains the issues that need to be
addressed for successful implementation of e-health in the healthcare sector today.
Chapter 6; This chapter provides the summary, conclusion, recommendations, contributions
and limitation of the study.
1.6 Chapter Summary
This chapter has dealt with the introduction of study. A brief introduction of the healthcare
sector in Kenya was discussed. The strategic issues that emerge from literature review were
discussed in brief. The research problem was discussed bringing out the conceptual,
contextual, empirical and methodological gap. Finally, the research objective and
significance of the study were explained. The analysis in this chapter shows that the
healthcare sector in Kenya is facing challenges when it comes to implementation of
technologies unlike other sectors like the financial sector. Thus it was justified to explore
this field further to try and understand the underlying issues that affect the implementation
of e-health systems and hence the motivation for this study. Grounded theory approach was
used for the study. The final outcome of this methodology was to develop a substantive
theory that was supported by empirical data that explains the issue of e-health
implementation in Kenya in detail.
15
CHAPTER TWO
LITERATURE REVIEW
2.1 Introduction
This chapter evaluates the literature on e-health and the issues that underlie its
implementation performance in several parts of the world. Both theoretical and empirical
studies are reviewed. From the review the gaps were identified to inform a general model for
the study. A conclusion on the review is drawn at end of chapter.
2.2 Definitions of e-health
Following the flare-up of the internet in the 1990s and the emergence of words such as
e‐Business, e‐Solutions and e‐Commerce, the term e‐health was introduced to represent the
promise of ICT to improve health care services (Eysenbach, 2001). Despite the lack of
consensus on a clear definition of e-health, there is an implicit understanding of its meaning
and the term is extensively used by industries, educational institutions, funding agencies,
professional bodies and many individuals.
“E-health is an emerging arena at the intersection of medical informatics, public
health and business, referring to health services and information delivered or
enhanced through the Internet and related tools to improve health care”
(Eysenbach, 2001, p.1).
An appropriate definition and the scope of e-Health may vary, but the most important
aspect is the perceived benefit attached to advanced technology use to improve healthcare
sector (Avgerou, 2008). The World Health Organization (WHO, 2012, p.6) defines e-Health
“as the cost-effective and secure use of ICT in support of health and health-related fields,
including health care services, health surveillance, health literature, and health education,
knowledge and research”.

16
These technologies are applied in the healthcare field to enhance the access, productivity,
efficacy and enhanced quality of patient care. In the support of this narration Alvarez (2003,
P.3) equally defines e-Health “as a consumer-centered model of health care where
stakeholders collaborate, utilizing ICTs, together with Internet technologies to manage
health, arrange, deliver and account for care, and manage the health care system”.
Moreover Pagliari et al. (2005) refers to e-Health as the usage of emerging information and
communications technology, especially the internet, to advance or enhance healthcare
management. These technologies are meant to improve quality healthcare outcomes.
Furthermore Ekeland et al (2010, p.2) adapts Elysenbach’s (2007) definition and describes
e- Health
“as an evolving field of medical informatics, referring to the organization and
delivery of health services and information using the Internet and related
technologies. In a broader sense, the term symbolises not only a technical
development, but also a new mode of working, an attitude, and a commitment
for networked, global thinking, to improve health care locally, regionally, and
worldwide by using information and communication technology”.
With regards to this study, e-Health is assumed as a wide variety of medical information and
communication applications for enhanced healthcare service delivery, together with
distribution of health related data. In addition they support clinical data storage and
exchange of medical information, between interpersonal communication, computerized
based support, patient-provider communication, education, health service, health community
and telemedicine, amongst other functions (WHO, 2013).
17
As evident from various definitions and research perspective, the central goal of e-health is
its contribution to quality healthcare and effective performance of the healthcare system.
Furthermore Korpela (2013) notes that e-Health could give power to patients and help in
exceeding information asymmetry between principle partners while guaranteeing that
dependable and suitable clinical data is accessible for operational and key basic leadership.
In addition e-Health frameworks together with organizational changes and improvement of
new skills can turn as key empowering instruments to encouraging critical upgrade in access
to quality of care, and additionally proficiency and efficiency of the health care systems
framework. On the other hand the implementation of e-health systems may contribute to
achievement of vision 2030 social pillar goal that is to ensure there is equitable and
accessible healthcare to all citizens. As well as attaining the sustainable development goal
number 3(SDG) on ensuring good health and well being for all citizens.
By and large Bhatia (2014) concludes that the utilization of ICTs in the healthcare sector
tends to concentrate on three general classes: (i) enhancing the working of healthcare
frameworks through enhancing data accessibility; (ii) enhancing the conveyance of health
care services through better diagnosis and improved treatment; (iii) improving
communication about general health, amongst healthcare workers and the general society.
Moreover e-Health systems are seen as having the likelihood to improve efficiency, reduce
administrative costs, expedite communication, and enhance patient care (Mishra, 2007;
Avgerou, 2008).
18
2.2.1 Forms of e-health
E-Health comprises of various applications that underpin patient management and care.
These applications include electronic Medical Records (EMRs), Telemedicine, Health
Knowledge Management, Consumer Health Informatics (CHI), M-Health and Healthcare
Information Systems (HIS). Telemedicine is the sharing of medical data between two groups
situated at various geological locales by means of a media transmission link (WHO, 2012).
Telemedicine includes video conferencing, where data exchange between health workers
and patients is done via a video link (Berler, 2006). In the same context Bhatia, (2014)
refers to telemedicine as the application of ICT innovations to triumph over barriers such as
physical and time constraints in treatment of specific conditions.
Mbarika (2012) asserts that used astutely, telemedicine can be an economical method in
competence building in the health care frameworks of several countries. Health Information
systems also referred to as health management information systems (HMIS) on the other
hand are systems used to gather, analyze, maintain, retrieve and evaluate health information
(Alvarez, 2003). In addition WHO, (2011) notes that a health management information
system integrates all data and makes it available for use to improve and protect population
health. According to Lazaro, (2013) the objective of Health Management Information
System is to consistently check on quality of service through comparing set standards and
perception of service delivered. Avgerou, (2008) refers to Mobile health as the use of mobile
communications in order to improve healthcare service delivery. Furthermore Mishra,
(2007) suggests that the usage of the internet and mobile devices has created new
possibilities for health promotion and management. Moreover these tools may be used to
enhance access to various sources of knowledge for all parties including patients, health care
providers, and the general population.

19
Electronic Medical Records (EMR) also commonly referred to as Electronic Health Records
(EHR) are applications that are used to keep patient's clinical history and support medical
activities by healthcare specialists. They include information such as laboratory results,
treatment and general patient medical history. Thus electronic health records provide the
storage, and facilitate communication of patient information among different healthcare
specialists. Moreover the care givers can access the patient information electronically
through use of certain authorization (Anwar, 2012).
Eysenbach, (2007,p.5) defines Consumer Health Informatics (CHI) “as a health informatics
that analyzes customer’s needs for information, studies and implements approaches of
making information accessible to consumers, models and integrates consumer’s preferences
into medical information systems”. Consumer Health Informatics (CHI) provides
information to the general public which ultimately promote self-care, informed decision
making, peer information exchange and promotes healthy behaviours (Hedström, 2012). On
the other hand Health Knowledge Management tools provide great support to exploit the
huge health knowledge and information resources. In addition while assisting today’s
healthcare organizations to strengthen healthcare service effectiveness. Similarly they
provide an overview of up-to-date medical journals, finest practice guidelines or
epidemiological tracking of trends and management of diseases. Some of these examples
include physician resources such as Medscape and MDLine (Juma, 2012). In general all
these applications are intended to improve the patient's diagnosis and treatment while
increasing organizational productivity at minimal costs (Boonstra et al., 2014).
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2.3 Issues in E-health Implementation
According to Gichioya (2005) obstacles to ICT implementation include inadequate
infrastructure, scarce funding, weak data systems and incompatibility coupled with unskilled
workforce. In addition leadership styles, negative organisational culture, and bureaucratic
procedures are a major hindrance. In Kenya for instance these barriers among others include
insufficient funding and poor leadership styles (Kukali, 2013). Literature review on e-health
implementation is quite extensive but the most strategic issues addressed in the articles are
acknowledged as falling into five significance areas. They include namely: e-Health
standards; ICT and health policies; e-legislation; e-Health infrastructure; ICT competence
(Xiangzhu et al., 2013; Mugo, 2014; Lazaro, 2013; Juma et al., 2012; Korpela, 2013;
Murray, 2010; Mbarika, 2011; Braa, 2007; Oladosu, 2009b ; Jennet & Siedlecki, 2001).
2.3.1 ICT and Health Policies
The literature on e-health policy and strategies, in general, is fairly current, and scarce. The
existing articles mainly focus on the need to address the e-health policy issue at both
national and international levels. However, most governments in both developed and
developing countries have made an initiative of establishing ICT policies for healthcare
(WHO, 2011). Oladosu, 2009 & Mbarika, 2012 notes that the objectives and goals of the
various institutions are rather similar. Nevertheless, the level of defining the policies and
transforming them into projects and programs differs from country to country. Murray
(2010, p.2) defined “e-health policy as a set of statements, directives, regulations, laws and
judicial interpretations that direct and manage the life cycle of e-health”. According to the
WHO, (2011) policies in an organization help in developing a vision for the future. Equally
they act as reference for short, medium and long-term objectives. In addition they assist
when setting out priorities, delegating roles and defining action to be taken in the
21
organisation. Moreover policy and decision producers in the larger health system must see e-
health as a key player in provision of improved healthcare service. In that regard ITU (2015)
encourages ministries of health to work together to develop an integrated e-health policy that
is standardised across all countries.
In addition, Korpela (2012) recommends that e-health policy needs to be integrated into the
existing healthcare system policy in a practicable manner. Basically, numerous e-health
assignments in developing nations, especially in less developed nations, are executed and
assessed as stand-alone (pilot) initiatives. Murray (2010) attests that a significant part of the
supplication of e-health stays instinctive, and is based on fragmented rather than
experimental research. A few papers talk about the real requirement for a policy in e-health
(Lazaro, 2013; Oladosu, 2009 and Murray, 2010). Privacy and confidentiality have appeared
as significant policy issues for e-health implementation. Nevertheless, policy development
severely slows e-health enhancement. Thus Korpela (2013) stresses that setting up a policy
or an approach in developing e-health projects is the answer to the realization. The WHO
contends vivaciously for informatics rules that are, in a nationwide setting, carefully built in
across all sectors, institutionalized, and thoughtful to local and regional interests (WHO,
2013).
In Kenya, for example the Government in affiliation with the private sector has made
significant steps towards making approaches and techniques for the uptake of e-health. For
instance, the Strategic Plan for Health Information Systems (HIS) (2009-2014) and the
Kenya ICT policy (2006). Thus the Kenya Health Policy, (2012 – 2030) offers captions to
guarantee impressive change health status in Kenya in accordance with the country long
term development agenda, Vision 2030, the Constitution of Kenya. Moreover there is a
22
national e-Health ploy. This ploy shows a plan that the healthcare sector will use to achieve
an effective and efficient healthcare system. One noteworthy challenge to the effective
implementation of e-Health in Kenya is the lack of an e-Health Policy set up (Ministry of
Health, 2013).
2.3.2 E-legislation
The utilization of ICT networks strategies is the major difference between e-health and the
traditional face-to-face healthcare delivery. Consequently, privacy, confidentiality and
security are significant issues related with e- health implementation. Furthermore the
utilization of the internet for transmitting patient's data online is an issue of disquiet.
Subsequently privacy, discretion and safety issues arise when patient care is passed over a
distance or by means of a network (Mugo, 2014). In that regard the web is considered to
likely assume a critical part in e-health administration. Thus Xiangzhu et al., (2013)
highlights protection, security and confidentiality as key issues influencing the
implementation of e-health in the sector.
Without a doubt many developing countries are inadequately prepared to keep up sufficient
levels of patient’s data protection. It is very much acknowledged that the act of e-health is to
a great degree data sensitive. For most clinicians the necessity that patient related data ought
to be kept private, is a center component of guaranteeing that the trust the patient places in
the clinician by sharing personal data is not damaged (Mugo et al. 2014). Ideally clinical
treatment, depend significantly on hearty, precise, proper, and opportune data and that the
data is a fundamental segment of e-health frameworks. Some type of record keeping of
experiences between the clinician and patient has been key to enhancement of patient care.
23
Therefore a fully incorporated, available, secure, and searchable electronic health
information is both a vehicle for tremendously required change in healthcare sector. This
additionally represents a noteworthy potential danger to security in e-healthcare systems,
and accordingly it is critical to create moral and legal structures for the assurance of
protection of patient's data particularly where care is being offered over a distance for
instance through telemedicine (Lazaro, 2013; Mishra, 2007).
Typically issues of information framework security emerge as an issue of enthusiasm for the
e-health administration. Information framework security is alluded to as the safeguarding of
information frameworks against illegal access to, or adjustment of, data whether away,
preparing or transit and against the renunciation of service to approved clients or allowing
access of service to unapproved clients (Oladosu, 2009; Ronen et al., 2011). A few e-health
periodicals tackle the need to create security and standard polices, however not very many
articles address the issue of protection, privacy, standards, and security in developing
countries. Security and confidentiality articles are relatively recent and moderately few in
developing countries (Bossen, 2013). Without a doubt the larger part of the available articles
has pinched from spotlights on the ICT administration in general, and the encounters of the
developed nations (Bhatia, 2014).
The ITU and WHO have delivered some reviews that look at the impacts of security and
confidentiality issues in developing nations (ITU, 2012). In developing nations, e-health
innovations are associated with issues about protection, security, and discretion for an
extended period, more than security issues in different segments (Murray, 2010 and
Xiangzhu et al., 2013). Largely these issues require initiating a procedure to address risks
particularly connected with their application to e-health frameworks. Subsequently, the key
24
issues of e-health security frameworks are identified with the safeguarding of discretion,
reliability, accessibility, and liability of the frameworks. Typically security and secrecy of
electronic health transactions over networks offers real concerns to all e-health suppliers,
patients, and different partners (WHO, 2013).
Basically lack of electronic enactment for a case in point has undesirably influenced e-
Health implementation in Kenya. The ICT regulatory sector in Kenya is represented by
different legal instruments including the National ICT policy 2005, the Kenya
Communications Act 1998; the Kenya Communications Regulations 2001 and Kenya
Communications Amendment Act (KCAA, 2009). The Kenya Communications
(Amendment) Act, 2009 in any case, does not address all parts of e-exchanges, e.g
discretion of data and ethics. Generally users of e-health frameworks need to be assured
about privacy of the patient’s data online. Currently the Health bill 2015 is at present
undergoing review. The bill is an ACT of Parliament to set up a combined healthcare
framework, to synchronise the inter relationship between the national government and
county government health frameworks. In addition provide regulation to healthcare
management and healthcare workers, products and healthcare innovations for connected
purposes (Health Bill, 2015).
2.3.3 E-Health Standards
One of the real impediments to e-health implementation is the incapability of health data
frameworks (HISs) to interoperate with a specific end goal to share data. A standard is
viewed as indispensable to attaining interoperability. Even so, the e-health Standards field is
stacked with numerous difficulties, the key of which is the immense number of accessible
standards, with a large portion of them contending and overlapping, while others
25
controverting each other (Braa, 2007 and Juma, 2012). A standard is a settled upon,
repeatable method for accomplishing something. Fundamentally it is viewed as the key to
accomplishing interoperability of e-health data frameworks. A standard could be formal,
exclusive or open (Braa, 2007). Standards are amongst the most noteworthy issues for the
effective advancement and success of e-health frameworks. This is on the grounds that a
significant number of the standards are created autonomously of the organisation initially
setting up the standard. In addition many issues concerning policy forming and basic
leadership about the implementation of e-health frameworks are connected with the working
of an open standardised setting (Fanta et al, 2015).
The capacity of standards in e-health need be found in the setting of healthcare institutions,
the innovation drive, and the diverse interests of the distinctive performers. Any distinct
association or venture required in e-health applications needs to settle on its own choices
concerning official standards, real models, and proprietary solutions (Korpela, 2014 and
Juma, 2012). For all e-health framework clients, the Open Systems Interconnection (OSI)
principles address many functions, for example capacity, transmission rates, protocols, and
security. Similarly e-health data frameworks security standards are basic for guaranteeing
the privacy and reliability of patient data. Notwithstanding, e-health is not the same as
different technologies regarding both stability and standards. Thus considering the extensive
variety of innovations and applications utilized, standards should be produced for the
management of e-health frameworks particularly (Braa, 2007 & Murray, 2010).
Consequently continuity is required for the provision of a dependable, proficient, secure and
superiority level of patient care. In addition a solid telecommunication lines and electrical
power framework is necessary.
26
However, existing publications on embracing of e-health standards revealed that the
moderate pace of the acceptance of standards both by developed and developing countries is
as a result of a few elements. These categories incorporate the expansive number of
standards that are being created by the different nations. Without a doubt this is aggravated
by the way that e-health standards do not tackle one bound area of innovation (Korpela,
2013). Furthermore there is presence of contradictory and overlying guidelines. Additionally
there is the problem of consolidating standards from various nations as well as the increased
cost of changing over to new standard-based solutions (Braa, 2007). Moreover, adequate
guidelines for diagnostic imaging, interoperability, programming, transmission,
infrastructure, engineering, health informatics, and bioinformatics are yet to be defined in
developing nations (Juma et al., 2012). Nevertheless, Kenya has made great strides towards
developing e-health standards with the release of the Standards and Guidelines for
Electronic Medical Records (EMR) in Kenya (2010). However the standards do not address
Medical record portability, privacy and ownership which are major concerns for e-health
implementation (Juma et al., 2012). Indeed the ISO27001 standard ISMS (Information
Security Management System) does not address the e-health privacy related issues.
2.3.4 E-Health Infrastructure
Typically a country needs a solid ICT infrastructure to provide a platform for e-health
systems (Mbarika, 2012, 2013). The ICT platform primarily includes phone lines, fiber
trunks, submarine cables, T1, T3, OC-xx, ISDN (integrated services digital network), DSL
(digital subscriber line), and other high-speed services used by businesses, as well as
satellites, earth stations, and teleports. A well-defined infrastructure platform is an essential
ingredient for any country to realize the success of e-health frameworks. Such platforms
ought to likewise incorporate telecommunications, electricity, access to computers, Internet

27
hosts, ISPs (Internet service providers), and available bandwidth and broadband access
(Qureshi et al., 2013). Generally organisations would need high bandwidth in order to
provide high-quality multimedia content and thus provide a rich e-health experience.
Subsequently ICT infrastructure is without a doubt a significant requirement in e-health
implementation. Equally networks are now a significant element to enable healthcare
institutions to share and exchange health information. Thus the internet is one of the useful
and inexpensive ways when searching patient’s information online by the healthcare
professionals (Anwar, 2012).
Internet refers to the interconnection of computer networks using a standard packet
switching protocol for communications (Korpela, 2013). Although the internet has
significantly affected the processes of healthcare delivery, it is only one of the tools used in
“digitizing” and enhancing the management of healthcare information. Generally a large
amount of the research about e-health technologies has taken place in developed countries
than developing countries. Furthermore these countries have a relatively appropriate
infrastructure platform already in place, and extending and increasing the existing health and
telecommunications infrastructure have facilitated rollout (Odedra et al., 1993 & Korpela et
al., 2014). Hence for developing countries without a developed telecommunication
infrastructure platform, the transfer of e-health presents precise problems. Moreover in many
of these developing countries, implementers of healthcare applications based applications
are faced with intricate hurdles such as insufficient funding, inadequate resources and fragile
healthcare infrastructure. In addition, some countries may have just an elementary
application level of healthcare technology (Boonstra et al., 2014).
28
One of the leading countries in launching a complete and robust e-health infrastructure is
Singapore. By and large, Kenya has made extraordinary stride in the last decade. Basically it
has experienced substantial improvement in ICT infrastructure (National Broadband
Strategy, 2013). Since 2000, the division has outpaced all other in the Kenyan economy,
developing largely by around 20% every year (World Bank Economic Update, 2014). This
has been principally due to the major advancements in infrastructure, favourable
government policy, as well as an active and innovative private sector. Significantly
numerous Kenyans are presently interacting effectively with innovations as far as
developing and advancing of technology is concerned. According to Kenya’s
communications regulator in their Quarterly Sector Statistics Report (June 2016-2017),
Kenya has a mobile penetration of 86% (ITU, 2016). This figure is significantly higher than
the African average of 80.8%. Noticeably Kenya has also increased its internet usage with
82 out of every 100 persons having access to the net (ITU, 2016). Currently several
telecommunication companies are competing in laying out the fiber optic cable to
interconnect all major towns in the country. Basically the government has played a major
role in this improvement by lowering import taxes on ICT equipment and liberalizing the
telecommunication sector.
Furthermore the Kenya Government Communication Act (1998) was a precursor for
opening up competition in the ICT industry. Thus to ensure equity in access to broadband,
the Kenya government has formulated a strategy to ensure that all Kenyans have access to
broadband by year 2017 (The National Broadband strategy for Kenya, 2013). The main
purpose of the National Broadband Strategy (2013) is to provide quality broadband services
to all citizens. In regards to the benefits of broadband, the National Broadband Strategy cites
e-health as one of the benefits of broadband. This kind of connectivity would create an
enabling environment for the uptake of e-health.

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2.3.5 ICT Competence
Training on use of technologies among healthcare workers is cited as a critical contributing
factor to success of e-health implementation (Bossen, 2013). According to Mishra (2007)
training staff on use of technologies is a necessity in fostering positive attitudes about
electronic patient data management which in turn translates to greater acceptance and
implementation of e-health. Kiura (2012) attributes low implementation of e-Health among
developing countries to lack of IT know-how amongst the healthcare workers.
Fundamentally countries that have espoused training on use of technologies for healthcare
workers, acceptance of e-Health and utilization is relatively high (Korpela, 2012). This is
because training increases understanding and raises confidence level as users are able to
prevail over technophobia while relating utilization to expected benefits (Kimaro, 2005).
Likewise Lazaro et al. (2013) add their voice by arguing that optimal utilization of IT
towards the improvement of healthcare requires IT know-how across the healthcare field.
The association between training on technologies and implementation of e-Health is also
discussed by Juma et al. (2012) who observes that insufficient computer skills in the health
sector in Kenya elucidates the little implementation of e-Health. Qureshi et al. (2013) and
Murray, (2010) are of the view that those healthcare professionals who lack the IT know
how of processing the online health data end up spending too much time on the same.
Furthermore without sufficient computer skills, user participation in selection and
development of technologies becomes difficult which might lead to having e-Health
technologies that are not extensively accepted or used adequately (Murray, 2010 & Kaye,
2010). Additionally there is a chronic scarcity of clinical personnel in developing countries.
30
Besides, Kenya is one of the countries identified by the WHO as having a “critical shortage”
of healthcare workers. Undeniably Kenya’s healthcare infrastructure suffers from inadequate
clinical personnel. Namely Doctors 1:26,438 Dentists 1:236,686 Pharmacists 1:141,343
Clinical Officers 1:19,011 Nurses 1:2,465 Other Health Personnel 1:4,115 Non Health
Personnel 1:7,124 (Ministry of Health, 2013).
Moreover Kenya’s low physician density demands new solutions for improving doctor
communication and maximizing available human resource capacity. Thus e-health would be
the solution to this problem as many elements of medical practice can today be
accomplished even when the patient and health care provider are geographically separated
(Ministry of Health, 2013). In addition there is lack of computer training in health
professionals curricula and e-health leadership. Ideally in today’s highly dynamic
environments, organizational leaders need to rapidly adapt existing approaches to digital
transformation. Furthermore, without a common mindset between information system and
institution leaders, it is difficult to adopt new methodologies in reaction to changes in the
competitive technology landscape. Moreover e-health leadership would give guidance in the
design, selection, implementation and sustainability of e-health systems (Qureshi et al.,
2013; Ronen et al., 2011 & Juma et al., 2012).
2.4 E-health Frameworks
A number of frameworks for evaluating the factors that affect e-health implementation have
been proposed. Korpela (2013) used activity theory and secondary data to develop a
framework that is holistic towards information systems development (ISD) approach. This
all-encompassing methodology depends on combining hypothetical premise, for co-building
clinical data frameworks, work and general data frameworks in health care services. The
31
approach plans to be concerted in nature that addresses the domains of both clinicians and
normal individuals. While traversing the primary investigation and configuration
undertakings of socio-specialized data frameworks development from necessities evaluation
through needs setting to practical architectural solutions. However this framework does not
address contextual issues that are necessary for e-health implementation success.
Based on DeLone and McLean model on IS success, Bossen (2013) developed a framework
that integrated organizational, contextual and social factors as issues that affect electronic
medical records implementation. However the model only focuses on electronic medical
records application leaving out other e-health applications. Largely the framework is
critiqued of having left out technology as an aspect that influences implementation.
Sobowale et al.,(2011) developed a model for Computerized Health Management
Information Systems in Nigeria. The framework came up with three issues mainly financial,
political and cultural. Nevertheless it is critiqued for only focusing on electronic medical
records and leaving out other applications of e-health such as telemedicine and m-health.
Furthermore it does not address all factors that may affect electronic medical records
implementation such as technological and organizational as suggested by Qureshi (2013).
Later Blavin et al., (2013) modified and refined an existing conceptual model to guide the
review of selected published and gray literatures about the implementation and optimization
of e-health. This element of the framework is borrowed from the multiple perspectives
model as adopted by Ash et al. (2012). Specifically, they joined the multiple perspectives of
a systems-based theoretical model for understanding complex organizational systems, with a
hospital-focused framework on the stages associated with electronic medical records
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implementation and use. This framework incorporated organizational, specialized groups,
and technological perspectives issues that must be considered at each successive phase of
implementation. In essence this model essentially looked at e-health from electronic medical
records point of view while neglecting other forms of e-health.
Similarly Mugo (2014); Mbarika (2012); Akanbi (2011) focused mainly on electronic
records implementation while leaving out other forms of e-health applications. Braa (2007)
used complexity science theory and came up with a framework for standards for e-health
implementation that can adapt to a changing healthcare setting. This model neglected other
key issues that are significant to e-health implementation and only focuses on standards
alone. Connor et al., (2015) developed a framework that has three factors financial, technical
and human as issues affecting healthcare. This model only focused on one application of e-
health that is m-health while silent on other applications. Ouma’s (2008) case study
examined the factors affecting e-health in rural areas. They developed a framework that
included infrastructure, expertise and government policies. However this model is critiqued
of having left other significant issues such organizational factors as suggested by Alvarez
(2003) on the importance of having an integrated framework that is explicit and links the
implementation process with the wider organization context. This framework is applied to a
substantive case to integrate relevant organizational levels and distinct activity domains.
Lazaro (2013) investigated the challenges facing the implementation of e-health. The
framework included low ICT budgets, poor infrastructure, and unreliable electricity supply.
This model generally looks at e-health from an operation point of view and not a strategic
perspective. Moreover the model tends to ignore the institutional factors within which e-
33
health innovations are developed and implemented. All these frameworks tend to look at e-
health systems in terms of technological perspective and fail to capture the non-
technological perspective including critical interactions of significant stakeholders such as
providers and patients.
2.5 Theories of E-Health Implementation
In order to ground further understanding of e-health implementation in a developing country
context, three information system theories: Technology Organization Environment Model
(TOE) and Actor network theory (ANT) are evaluated in addition Grounded Theory (GT)
approach was reviewed as alternative to traditional IS theories.
2.5.1 Technology Organization Environment Model (TOE)
The Technology Organization and Environment (TOE) model was produced by Tornatzky
and Fleischer (1990). The structure recognizes three perspectives that impact the procedure
of institutions implementation of innovations: technological setting, organizational setting,
and environmental context. Technological setting looks at both the interior and exterior
innovations applicable to the institution. These incorporate existing innovations and
practices inside the institution, and in addition the pool of accessible advances in the market.
Organizational setting alludes to distinct measures about the institution, for example, degree,
estimate, and administrative structure and interior assets, accessibility of slack assets.
Environmental setting is the field in which a firm directs its business, its industry,
competition, and dealings with the government (Tornatzky and Fleischer, 1990).
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TOE model is predictable with the DOI model, in which Rogers (1995) underscored singular
qualities, and both the interior and outside elements of the institution, as affecting
hierarchical imaginativeness. These are similar to the technology and organization setting of
the TOE system, yet the TOE structure additionally incorporates another vital segment,
environment setting. As indicated by Tornatsky and Fleischer (1990), TOE settings of a firm
can impact the implementation process. Subsequently, Rogers' model of DOI jointly with
TOE structure would give a helpful hypothetical model to clarify the institution
implementation of IS.
The technological setting of an institution is critical in modelling the implementation of e-
health (Chau, 2001). Information on the utilization of existing technologies can be utilized to
boost the presentation of innovations and learning of new innovation can highlight the
openings accessible for the institutions to be creative. Additionally, researchers have joined
parts of DOI with TOE to build comprehension of organizational IT implementation
(Iacovou et al., 1995). Particularly they proposed that the technological setting in TOE
incorporates the information of development components from DOI. Factors such as
technology preparedness are connected with the implementation choice of e-health.
Generally when institutions have some basic knowledge on starting and implementation of
e-health systems, can draw on their experience on technological preparedness to booster the
implementation of new innovation. For instance, Lu, (2005) found that health institutions
with lower technological preparedness had poorer chances of e-health systems
implementation. Similarly technology preparedness is observed to be identified with
enthusiasm of the management to novel innovation. For instance, Lluch (2011) noticed that
the senior management’s preparedness to change influenced their eagerness to implement e-
health frameworks.
35
Organizational factors in healthcare sector stresses the function resources and capabilities
play in affecting e-health implementation decisions. For instance, Chau, (2001) noticed that
having sufficient resources is a significant determinant for implementation of electronic
medical records systems. This likewise incorporates having adequate technological
awareness. Other than having adequate resources, organizational capabilities such as
information processing ability and project team ability may be significant in the
implementation decision of e-health. Environmental elements particularly recognizable for
the hospitals are government contribution through policies. This can impact the choice to
execute new frameworks. Indeed external vendor affiliation is also critical for
implementation of healthcare IT innovations, especially when the organization is unfamiliar
with the technology (Iacovou et al., 1995; Chau, 2001 ). Moreover, business rivalry is found
to rekindle IT development implementation as health sector attempts to recruit more
customers to increase revenue by reducing inefficiency. TOE has been criticized as being
too general and not a good model of explaining complex issues such as e-health
implementation.
2.5.2 Actor Network Theory (ANT)
ANT is a model for examining how technical artefacts come into being. It generally
evaluates the function of technology in social situations and the processes by which it affects
or is affected by social elements in a setting over time. Mainly it concentrates on actors and
their endeavors to secure their interests by forming and reinforcing alliances in actor
networks which, in turn, generate technical artifacts for instance universal e-health
application. As the actor networks that generate these artifacts become stabilized, the
technical artifacts are said to be taken for granted or ‘irreversible’. Actors can be either
36
human or non-human entities that can make their presence independently felt by other
actors. ANT offers a balanced treatment between the technical and the social aspects of
technology, in that both human and non-human actors are treated similar. Fundamentally
technical artifacts are dealt with as good actors. Whereas they might be quite recently only
physical, specialized ancient rarities constitute a dynamic epitome of actor’s subjectivities,
together with their thought processes, expectations, interests and partialities (Cresswell et
al., 2010).
Essentially utilizing ANT can be beneficial mostly to investigate the improvement of
intricate technology such as e-health. Subterranean ANT permits examination to be centered
on an actor networks as a portrayal of multifaceted social connections comprising of
entrepreneurial political actions and transactions that happen keeping with the end goal of
selecting supporting actors or partners. Effective enrolment in a system shows the
arrangement of the generally various interests of its actors. In this manner there are two vital
ideas supporting ANT, inscription and translation. Inscription means that actors that come
up with an artifact try to engrave their interests into it. When these interests are engraved
they may be demonstrated as precise anticipations and limitations regarding future
utilization trends of the artifact. The artifact, thus, becomes a real actor that has the
capability to enforce the engraved interest onto other actors, i.e. the users of the artefact
(Latour, 2005).
By and large ANT gives a valuable medium to apprehend actors connection in the
improvement of pervasive e-health applications for some reasons. To begin with, by
concentrating on actor networks as the major building block for creating omnipresent e-
health arrangements, ANT looks at the relationships between actors as obscure social
37
interactions comprising entrepreneurial and political activities and negotiations. That is it
inspects the way in which actors shape, fortify, and keep up systems of actors collusions in
connection to universal e-health arrangements, and how their goals are locked into patterns
of connections and in processes of on-going arrangement of different benefits. By focusing
on the developing procedure of their building, as opposed to concentrating on pre-defined or
fixed elements, insight can be produced regarding the usefulness of the functions of e-health
applications and the form that they will (or will not) take in addition to drawing concerns to
both anticipated and unanticipated outcome of their usage in health care situations
(Wickramasinghe and Schaffer, 2005).
Consequently ANT permits looking at such inquiries as how and why omnipresent e-health
arrangements “come into being and how users and other actors conform, ignore, modify, or
usurp the original designers’ interests” (Cresswell, 2010, pp. 4-5). In doing as such, ANT
can assist examine the variability of the healthcare reality and the primary obscure actor
exchanges as they unfold. Various reviews have been found where ANT has been viably
used to explore various issues in health sector segment. For instance, ANT has been utilized
to analyze the implementation of electronic patient data, the improvement of indoor smoke-
free rules in relation to tobacco utilization policy, advancement of quality mental health care
management, development of information frameworks in psychiatry treatment, and the
improvement of diagnostic testing innovations. However ANT is critiqued for its intrinsic
limitations in providing empirically provable evidence by presenting a rich terminology.
Similarly the model is too descriptive and fails to provide comprehensive suggestions of
how actors ought be seen, and their actions investigated and translated especially in
healthcare sector (Cresswell et al., 2010).
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2.5.3 Grounded Theory (GT)
Given the intricacy and the fast-moving ever-changing field of the healthcare field and its
distinctive occupational dynamics, a single theory in itself, may not be an appropriate
methodology for explaining e-health implementation, hence it was useful to adopt a theory
building approach in order to explore this phenomenon in detail. This gave the researcher a
lucid and more precise picture into the key area of healthcare operations. Fernández and
Lehnmanm (2005, p.2) maintained that for research to remain significance in the evolving
fields such as healthcare, researchers needs to come up with new methodological
alternatives “a new methodological alternative: grounded theory building research, where
the emerging theory helps explain, in conceptual terms, what is going on in the substantive
field of research”.
Several other approaches may have the effect to force preconception through the transfer of
erroneous theoretical suppositions on the area of study. The Grounded Theory approach
overcame these problems by providing a window that does not bias surface with a priori
suppositions and does not push towards a choice of predetermined theories from which the
researcher must elucidate the socio technical phenomena (Walsham, 2006). GT concept is
offered as an inductive approach, whose focus is to come up with theories of an intricate
nature based on observed evidence. Grounded theory was presented by two American
sociologists, known as Barney Glaser and Anselm Strauss in their book the Discovery of
Grounded Theory in 1967. It was dependent on both nursing and sociology disciplines.
Glaser’s definition of grounded theory is “a general methodology of analysis linked with
data collection that uses a systematically applied set of methods to generate an inductive
theory about a substantive area” (Glaser, 1992, p. 16). Besides Grounded theory has proven
39
to be a more preferred qualitative approach for several researchers in many fields of study.
In the recent past decade, the utilization of GT approach has seen a rising interest among IS
researchers (Orlikowski, 1993; Bryant, 2000; Lehmann, 2010). For instance, Orlikowski
(1993), who got MIS quarterly’s top paper award for 1993. The researcher utilized GT to
come up with a model for implementation and utilization of computer-aided software
engineering (CASE) tools in distinctive institutions. The notification for the significance of
the approach is that it permits looking at the contextual and well-organized pieces on the one
hand. In addition it permits concentrating on the activity of primary actors related with the
components of organizational change that are frequently not addressed to in IS research.
Ideally GT varies from various other qualitative approaches, as it permits the development
of theories straight from the unprocessed data. Typically in this method data gathering and
analysis is done in a consistent way, and keeps the data to be original, instead of compelling
data to fit with existing theories. Besides, the theory does not look out to devise and test
hypothesis based on earlier exploration, but ideally seeks to make the research questions
general, open and flexible. In addendum GT approach, and through what is recognized as
theory sensitivity, gives the researcher a chance to conduct a cross examination of empirical
data gathered with the objective of finding resemblance and divergence between the
categories and its properties in an endeavour to look for universal trends in the data. This is
known as theoretical fundamentals of a theory (Corbin & Strauss, 2015).
However, similar analysis of the data that is gathered will proceed with until disclosure of
all potential categories, those inconceivability for discovering new subjects in the data,
furthermore a large portion importantly, validation of the theory. This is known as
theoretical saturation, whereas the process by which the data gathering and sampling is done
is called theoretical sampling (Kearney, 2007). As stated by Bryant, (2009) there may be an
40
acceptable contrast between the vocabulary of statistical or random sampling and theoretical
sampling. This contrast might have been additionally affirmed by (Strauss, 1967, p. 24) who
suggested that “the purpose of theoretical sampling is not to get a random sample or a
representative of the population, but to identify groups of people that have certain
characteristics or conditions such as those that surround the social phenomenon to be
studied”.
Generally the principle about grounded theory procedure concentrates on coding and
categorisation, the place the researcher will be skilled about seeing that gradual
improvement of the theory. In other words, the theory is steadily evolving from empirical
data through the continuous comparison method to analyse the data. Glaser and Strauss
(1967) in their study states that those stages of the steady analysis stages take
“first by comparing incidents applicable to each category, second, integrating
categories and their properties as the coding continues, the constant comparative
units change from comparison of incident with incident to comparison of
incident with properties of the category that resulted from initial comparisons of
incidents, third, delimiting the theory, and finally writing theory” (1967: p. 105).
Equally Glaser and Strauss (1967) stressed the importance of gathering memos for every one
possible categories, as it gives a reference point by examining issues identified with the
developing theory, “the researcher can formulate hypotheses about relations between
categories and their properties through collecting memos”(p.92). Virtually, this will assist
the researcher to distinguish that data behind the hypothesis, while filling the gap that exist
in the evolving theory, alternately with data gathering, give descriptions around those
concerning the developing theory. Over time GT methodology developed prompting a
division between Glaser and Strauss on the type of each style and how best it is applied.
41
Charmaz (2014) highlights the differences between the two styles. Glaserian style emphases
the benefit for control to preserve restraint, reliability and independence of the approach,
which permits for the problem being researched to produce the theory. On the other hand the
Straussian style emphases on the vigorous involvement of the researcher in the problem
being studied, as well as the investigation and utilization of all probabilities in the data
gathered. Nonetheless in spite of the contrasts between the two styles, there are similar
issues. The similarity is seen in wording and the method used between the two styles,
namely; the theoretical sampling, continuous comparative analysis, theoretical sensitivity,
memo writing, recognition of a core category, and theoretical saturation. Bryant, (2009)
emphasises that coding is of great importance in the appearance of theories. There are
various types of coding, namely the open, axial and selective. Open coding intends to
scrutinize the information gathered line by line or word by word, and in this way investigate
as many classifications or categories as could be expected under the circumstances. Axial
coding is intended to define the core category, which represents most of the variation in a
pattern of behaviour (Wolfswinkel et. al, 2011), or other categories and properties that
directly relate to the core category. However, the core category can lead the researcher to
gather more data. Axial coding was presented by Strauss, 1987 (p.79), “axial coding refers
to the process of re-organising the data broken in new ways by building links between the
categories and subcategories to them”.
Furthermore Strauss and Corbin (1990) add that the selective coding should be focused on
the use of coding paradigm, containing the setting, environment, and work/interactive
strategies and consequences. Selective coding focuses on finding the link between codes or
categories and their related properties, which are generally created from the axial coding.
These associations lead to the building of hypothesis, which are later integrated into the
42
theory. Moreover lack of utilizing the coding paradigm may weaken the up coming theory.
In contrast, Glaser (1992) argues that probing more of preconceived facts and considerable
issues during the analysis of the data frequently end up forcing rather than freely letting the
development of the theory. Additionally he notes that Strauss and Corbin are no longer using
grounded theory, but rather a new approach. Furthermore this is seen as an endeavour to
present a realistic directive to experienced researchers, not only on the foundation of the
grounded theory approach but also on other qualitative research approaches.
2.5.3.1 Differences between Glaserian Version and Straussian Version

The following table 2.1 shows the differences between the two approaches (Goulding,
2009).
Table 2.1 Differences between Glaserian and Straussian versions
Dimension Glaserian version Straussian version
Developme Everything arises in a grounded The investigator adopts a more active and
nt and theory – nothing is forced or stimulating influence over the data, using
researcher predetermined. Researchers are amassed knowledge and experience to
distance aloof and unknowing as they enhance sensitivity. Logical elaboration,
approach the data, with only the and defined tools and techniques can be
world under study shaping the employed to shape the theorizing.
theorizing.
Developme The goal is to generate a Conceptually solid, integrated theory
nt of model conceptual model that accounts development is the only legitimate product.
for a pattern of conduct which is Grounded theory can also be used for
pertinent and problematic for evolving non-theory (conceptual ordering
those involved. or elaborate description).
Specific, The technique includes clear, GT incorporates various discrete strategies
non- expansive, thorough methods and that must be done. Researchers can browse
optional a set of crucial procedures that from a variety table, from which they can
procedures must be taken into account. pick, dismiss, or disregard.
Core The hypothetical definition that The fundamental subject of a prearranged
grouping focuses the steady settling of the phenomenon which joins the various
fundamental concerns of the categories and clarifies the different
contributors. actions and connections that are meant for
dealing with the important incidents or
happening
Coding Open, selective and theoretical Open, axial and selective,
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Nevertheless Fernández, (2005) observes that the choice of the suitable style of grounded
theory is based on the following points: 1) philosophical perspectives, paradigm of inquiry
and methodological positions, 2) intended outcomes, 3) theoretical and methodological
underpinnings, and 4) dual crises of representation (write-up of the theory) and legitimation
(rigour of the study). However Bryant and Charmaz, (2006) concludes that as such there is
no ideal approach to attempt grounded theory study, as it has no standardized and plainly
obvious clarification. Additionally Charmaz, (2011) highlights the advantages presented by
GT methodology for IS research are the technique's ability to translate perplexing
phenomenon, its accommodation of societal issues (Glaser and Strauss, 1967), its suitability
for socially constructed capabilities (Charmaz, 2003; Goulding, 1998), its imperative for
appearance (Goulding, 1999), its absence from the constraints of a priori knowledge
(Bryant, 2007), and the approach’s ability to work with diverse types of researchers.
The method utilized by grounded philosophers to gather exhaustive data is an additional
benefit that is significant (Charmaz, 2006). Exhaustive data will make the “world appear
anew” (Charmaz, 2006, p. 14) “because the richness of the data will provide the researcher
with concrete and dense fabric to construct a thorough analysis of the data in addition to
aiding the researcher to go beneath the surface of the participants social and subjective life”
(Charmaz, 2006, p.14). Indeed Charmaz (2006) contended that the research exploration
begins with “finding data” (p. 14). As such data will expose the setting and structure of the
respondent’s lives in addition to “divulging their feelings, views, intentions and actions”
(Charmaz, 2006, p.14). Thus in order to gather extensive data, researchers are required to
search through thick descriptions through writing “extensive field notes of observation”
(Charmaz, 2006, p. 15). GT method provides the necessary apparatus for “making sense of
the data” (p. 15) and “refining it to generate insight into the phenomenon under study”
(p.16).
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2.5.3.2 Criteria for Evaluating Quality of GT Research Process
In spite of the way that grounded theory approach, has been displayed as a substantial and
significant technique to IS research, it is generally unusual for discoveries from any
subjective study to be judged for neglecting to attain certain benchmarks of legitimacy,
reliability and quality. Bryant and Charmaz, (2006) raise their concerns that frequently
researchers misconstrue grounded theory approach, not considering the thorough procedure
included. In essence Klein and Myers (1999) gave a system for assessment of qualitative
studies in IS. The purpose of the framework is to evaluate the meticulousness of the GT
research inquiry. They espoused a number of seven associated ideologies for the “conduct
and evaluation of the studies” (Klein and Myers, 1999: p. 70) that can be utilized for post
hoc assessments, ideally as it applied particularly for this study.
The researcher assessed the GT research inquiry by utilizing each of the ideologies, and
found that generally, the conduct of the study was sound. Moreover it is significant to note
that the gathered data was diverse and rich and may at present be liable to various
elucidations. According to Fernandez (2005: p.9) “what we have to do is recognise what it is
we who create and suggest that others test our generalisations and our conclusions based on
their own sense of meaning”.
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Table 2.2 Criteria for Evaluating Quality of Grounded Theory Research Process
Principal Evaluation in this study

1.The hermeneutic Data interpretations were routinely scanned for themes clarifying factors of
circle e-health implementation from various angles. Interviewees were contacted
to clarify encounters as narrated during the sessions. The research kept on
going over between the interview sessions and the actual day to day
experiences to establish the complete picture of e-health implementation in
Kenya. Extensive literature review was done concurrently with data
gathering to explicate the observed issues on e-health implementation
2.Contextualisation The data was gathered in natural environment where users had right to use
their records and tools utilised in e-health implementation. personal
encounters had a strong case on the direction to which activities were
portrayed and the essential factors were highlighted
3.Interaction Respondents were encouraged to air their views with no limitations on the
between the issues they felt were most significant. The researcher focused understanding
researcher and the specifically the issues that affect e-health implementation in Kenya, while
respondents politely requesting for additional substantiation where need be. The
researcher as well enticed the interviewee’s to share views unreservedly on
what they thought were the barriers to e-health success or failure in the real
life situation.
4.Abstraction and The data gathered was coded and examined for likeness and resemblance
generalisation which was essential in having a picture on the general elements for e-health
implementation in less empowered countries in general and Kenya in
specific. The process of coding assisted in the analysis of the problem under
study and provided a theoretical framework of e-health implementation, and
other issues around resolving the implementation issues.
5.Dialogical The preliminary comprehension of e-health implementation factors was
reasoning founded on the general IS implementation frameworks explained in the IS
literature. However, the researcher found divergences of common
methodological approaches from practice. The researcher thus resorted to
use a data driven model as opposed to adopt the constructs used in IS
literature. The collected data showed that stakeholders are not merely
apprehensive with the technical factors of implementation, but other parts
related to the settings of the implementation.
6.Multiple Stakeholders from various backgrounds revealed common problems
interpretations influencing e-health implementation in Kenya. However, e-health
stakeholders gave their contributions on how to handle every single
problem. By utilizing code generalisation, the researcher combined the
explanations and findings of the problem under study into a framework for
comprehending the elements that influence the successful e-health
implementation in Kenya.
7. Suspicion The researcher comprehends that data gathered may have had certain level
of bias. Thus this was solved by triangulating interviews where a number of
people were interviewed about the same issue. To avoid bias during coding
and interpretations Iterative data gathering and examination was
consequently useful to permit any such miscomprehension to be recognized
and then greatly reduced in the process.
46
GTM was criticized as being very intricate and laborious methodology owing to the
tiresome coding process and memo writing as part of the analysis (Charmaz, 2006;
Fernández, 2005). This was made easier by use of specialized software like NVivo to help
speed up coding and analysis of data.
2.6 Empirical Studies on Strategic E-Health Issues
By and large studies on E-health are numerous and diverse as described below. Mbarika et
al. (2012, 2011) study on factors affecting implementation of e-health in developing
countries found out that the most gruesome challenges for e-health implementation and
sustainability were lack ICT competence, e-health policy, e- infrastructure and resistance by
clinicians. All these responses are inline with works by, Kaye (2010) who decried lack of
ICT competence, e- infrastructure and management support for implementing e-health. They
identified e-health policy as a significant factor for sustainable e-health systems. Further to
this Lazaro (2013) had recognized inadequate resources as a big problem for e-health
sustainability. The researcher proposed a further study be carried out to develop a
framework for e-health implementation in developing countries context.
Correspondingly Fanta et al. (2015) evaluated e-health implementation frameworks in
South Africa. They came up with a framework that integrates environmental, social and
economic factors. Equally, Kimaro and Nhampossa, et al. (2007) qualitative study examined
barriers to e-health implementation and sustainability. The findings were lack of ICT
competence, e-legislation coupled with unfriendly interfaces. The researcher recommended
that a further research is done to find out the most significant factors that affect
implementation of e-health. Mugo et al. (2014) used secondary data in order to examine the
determinants’ of EMR implementation: The findings were that there was user resistance and
47
unpreparedness coupled with lack of ICT competence and e-legislation. Moreover the EMR
was not compatible with the way the family practitioners liked to practice as was oftentimes
seen as an intrusion in the examining room, in the patient-physician interaction. In addition
Xiangzhu et al. (2013) & Treurnicht (2009) had identified privacy concerns as a big problem
to EMR implementation. The researcher recommended that further research to be carried on
other forms of e-health applications in hospitals and find out if there is a correlation of
factors found in the above study.
Qureshi et al. (2013) cross sectional survey sought to find out the key factors that affect the
success of e-health implementation in developing countries. The findings were lack of ICT
competence, clinician résistance, lack of e-health policy and e- infrastructure. The researcher
proposes a further study to be carried in other settings to find out the correlation of these
factors. Indeed all these responses are inline with the five strategic issues discussed earlier
that affect successful e-health implementation by (Korpela, 2012; Mbarika, 2011). On the
other hand Braa (2007) came up with an approach that standardizes e-health implementation
however this approach left our other factors that are equally significant to its success.
Although Korpela, (2013) suggested a holistic approach to information system
implementation in healthcare it may contextually not be appropriate for developing countries
considering the underlying challenges. Juma et al. (2012) examined the current status of e-
health in Kenya. He used secondary data sources to review the study. The findings were that
there was lack proper e- infrastructure and e-standards in place to support e-health. He
recommended a further study to be done to determine the most significant factors necessary
for successful implementation of e-health in hospitals in Kenya.
48
2.6.1 Summary of Literature Review and Research Gaps
The empirical review above has highlighted certain areas that need attention. However these
issues are addressed from an operational point of view, whereby information systems are
perceived to be useful at operational level management. In this case e-health is equated to
information systems which support operational activities of healthcare. The review indicates
that most of the findings are addressed in discrete bits and pieces and there is no
comprehensive approach that is suggested on how these factors relate to one another to form
one comprehensive framework. The existing frameworks are not holistic as they only
address few aspects of e-health implementation. The frameworks have also been developed
mainly using secondary data. In addition the existing frameworks has been developed based
on positivist approach that forces certain prejudices unlike GT approach that allows for
theory to develop from data. Thus there is a need to come up with a comprehensive e-health
strategy implementation framework that would explain the phenomena. The table below
shows a list of gaps identified and it is suggested that these are the things that need to be
addressed to increase strategic understanding of e-health. The following is a summary of
research gaps that this paper has identified
49
Table 2.3: Summary of Research Gaps
Author Subject Methodology Findings Gap How it will be

and Theory addressed
Mugo et EMR Secondary User resistance Domain knowledge: Focus on other
al implementation data ICT competence focus is on Electronic forms of e-health
(2014) in Kenya e-legislation Medical Records
ICT unpreparedness leaving other forms of
e-Health applications
Lazaro et Underlying Secondary User resistance Methodology: Use Grounded
al Challenges of E- data ICT competence secondary sources may Theory
(2013) Health Adoption e- infrastructure be limited in unearthing methodology to
in Tanzania inadequate resources the problem as the explore primary
focus may not reflect data sources
the real situation on the
ground
Kimaro Implementation Qualitative ICT competence Methodology: currently Use grounded
(2007) of e-health in Case study Non user friendly looks at e-Health from methodology to
Mozambique Interpretive systems adoption from explore into the
Technology Clinician resistance operational point of factors that are
Acceptance e-legislation view and not strategic relevant to the
Model successful
implementation
of e-health
Mbarika Implementation Case study, ICT competence Methodology and Come up with a
et al and quantitative Lack of e-health knowledge: currently e-health
(2012, sustainability of qualitative policy looks at e-Health from implementation
2011) e-health in UTAUT and Resistance by adoption from framework from
Uganda and Theory of clinicians operational point of a strategic
Ethiopia Reasoned e- infrastructure view and not strategic perspective with
Action Grounded
Theory
methodology
Xiangzh EMR Secondary Framework for EMR Domain knowledge: Focus on other
u et al implementation data implementation that focus is on Electronic forms of e-health
(2013). in Australia integrates e- Medical Records
legislation leaving other forms of
ICT competence e-Health applications
Bossen Evaluation of a Case study DeLone and Domain knowledge and Use grounded
et comprehensive DeLone and McLean model that context; main focus is methodology to
al(.2013) EMR based on McLean integrates on EMR leaving out explore other
the Delone and model organizational, other forms of e-health forms of e-health
Mclean model contextual and
for IS success in social factors
Denmark
Braa Developing Complexity A framework for Context and Use Grounded
(2007) health Science standards that can methodology; Theory
information theory adapt to a changing This framework may methodology to
systems in health care not be contextually explore various
developing Secondary environment, and appropriate locally. The factors that are
countries: the data that are sensitive to framework does not key to the
flexible local context incorporate other issues implementation
standards that are significant to e- of the systems in
strategy in South health implementation Kenya
Africa
50
Author Subject Methodology Findings Gap How it will be
and Theory addressed
Kaye Barriers and Secondary Structural factors Context and Use Grounded
(2010) success factors data e- infrastructure methodology: study Theory
in health Cultural factors uses secondary data methodology.
information ICT competence Israel is way
technology in advanced in
Israel healthcare as
compared to
Kenya
Fanta An evaluation of Secondary Framework that Context: the framework There is need to
2015 e-health systems data integrates has left out a key use grounded
implementation environmental, technology issues. The theory to come
frameworks for social and economic factors are not up with
Sustainability in factors integrated to show any framework from
South Africa relationship This data, including
framework may not technology &
contextually apply in other factors that
Kenya may arise
Qureshi e-health barriers Cross ICT competence Context: the factors Use Grounded
et al in Pakistan sectional Clinician resistance may not be same as Theory
(2013) survey Lack of e-health what is happening methodology to
Actor policy locally. These factors focus on what is
Network e- infrastructure are not integrated to happening in
theory form a comprehensive Kenya and come
framework up with a
comprehensive
framework
Ronen R Implementation Qualitative Framework that Context: the framework Use Grounded
et al of information Case study integrates may not be applicable Theory
(2011). technology in technological, locally because of methodology to
healthcare in ethical and contextual issues come up with
Canada economic factors theory from data
that will build a
framework that
suits the local
situation
Juma et Current status of Secondary e-infrastructure Methodology: Use Grounded
al (2012) e-health in data e-standards secondary sources may Theory to look at
Kenya be limited in unearthing primary data
the problem as the sources to
focus may not reflect explore other
the real situation on the factors not
ground captured.
Korpela How to develop Action Came up with a Context: the framework Use Grounded
et al services work research holistic ISD may not be applicable Theory
(2013) and information Activity framework which is locally because of methodology to
systems in theory collaborative contextual issues. come up with
healthcare in between the users, theory from data
Finland system analysts & that will build a
organization framework that
suits the local
situation
51
2.7 Research Approach
The healthcare sector is intricate and multifaceted (Geri and Geri, 2011; Skyrius and
Bujauskas, 2010). A total reasonable comprehension of it needs the grappling of countless
entwined and converging issues and subjects (Bryant, 2002; Fernández and Lehmann, 2005;
Walsham, 1995). Grounded Theory study can provide to the researcher a thick description,
that assists untangle the issue being explored. This will offer some incentive to the
individuals who will benefit from the end product by giving important developing ideas
(Charmaz, 2006; Wolfswinkel, 2011). This research embraced the Straussian style of
grounded theory due to its prescriptive edicts than the Glaserian style which is more
emergent in nature. The Glaserian version approaches the study with an empty mind while
the Straussain style allows the researcher to begin with carrying out some literature review.
Thus the five issues (e-Health standards; ICT and health policies and strategies; e-
legislation; e-Health infrastructure; ICT competence) from the literature review formed a
starting point for exploration. Grounded theory allows open investigation depicting
emergence of concepts and showing their relationships. Concepts and relations are emergent
from data and cannot be predicted in advance.
52
The research approach that was followed is illustrated in the figure below.
Starting point
e-infrastructure, e-legislation, ICT competence, e-
standards , ICT policies & e-health policies
Interviews
Formal Theory
Transcribing
Substantive Theory Memo writing

Coding
Open Axial Selective
Figure 2.1: Research Approach (adapted from Charmaz, 2013)
53
2.8 Chapter Summary
In this chapter the applicable scholarly literature has been exhibited and fundamentally
explored. The area of e-Health has been discussed in detail. The primary conclusions that
emerge are that the e-health sector is not fully explored and implementation is still a
challenge especially in developing countries. Nonetheless, it is regularly acknowledged e-
health has a likelihood of reducing the cost and enhancing the quality of life of patients. The
information systems theoretical foundations were explored. Grounded theory approach that
was used for the study was discussed and critically reviewed. Previous researches in the
area of e-health were examined which showed lack of an integrated framework that
fundamentally explains how e-health can be well implemented in developing countries. The
factors are addressed as discrete bits and pieces therefore, this study generated a data driven
framework that explains how e-health can be implemented in the health care sector in
developing countries.
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CHAPTER THREE
RESEARCH METHODOLOGY
3.1 Introduction
In this chapter the research philosophy, design, sampling procedure, target population, data
gathering procedure, data analysis and methods undertaken to resolve the problem area have
been discussed.
3.2 Research Paradigm
Philosophical discussions looking into how to do information systems research has been the
focal point of a great part of researcher’s attention (Mingers, 2001; Weber, 2004). Among
around those imperative phases in the course of research design will be the thought of the
fundamental customs on how we see the world, and reinforced by group of practitioners
(Denzin & Lincoln, 2011). Typically, the convictions held by the researcher influence the
possibility to get to which the research will be designed, data will be gathered, analysed and
the findings of the study presented. Therefore, the perception of these suppositions by the
researchers, especially at the stage preceding the selection of research approach, is a vital
step that will widen the horizon for the perception of knowledge and acquiring it on the one
hand, and define the role of researcher in the research process, find the real course of
research and differentiate it from other research tracks on the other hand.
Weber (2004) emphasises that the comprehension of these suppositions, if overt or implied
role in playing a dynamic role in guiding the course in the IS research, and thus showed in
the research outputs in a positive way. Moreover Denzin and Lincoln (2011) emphasise that
in practice, these suppositions represent at a philosophical level; fundamental convictions
about the world people live in, that consists of the social level; rules on the best way to
55
direct research and the technical level; methods and techniques used to complete studies,
thus the emergence of the word paradigm. The word paradigm ‘was first presented by
Thomas Khun in his book, The Structure of Scientific Revolutions in 1970. Neuman, (1991,
p. 57) give a helpful meaning of a paradigm as a
“framework or a set of suppositions that explain how the world is seemingly
where, the paradigm of a science includes its basic suppositions, the important
questions to be answered or puzzles to be solved, the research techniques to be
used, and examples of what scientific research looks like”.
Kuhn (1970) to begin with utilized paradigms in perspective of a model to comprehend
research. He perceives paradigms as
“a set of beliefs and practices which is accepted by members of a scientific
community, which act as a guide or plan, dictating the kinds of problems
scientists should address and the types of explanations that are agreeable to
them”(Kuhn, 1970, p. 175).
Denzin and lincoln (2011) laid down a framework of the different suppositions underlying
the social science research. This outline has been utilized to establish the theoretical and
philosophical supposition fundamental to and supporting this study. The schema has been
introduced on the structure of a grid comprising from claiming two measurements or sets of
presumptions around social science and the society. Furthermore, the social sciences extent
will be in view of a subjective/objective aspect. This incorporates four presumptions
identified with the social science study, in particular ontological, epistemological,
methodological suppositions, and presumptions regarding free will.
56
According to Bryman (2001) ontological presumptions are concerned with the type of the
planet and on individual persons in the social setting. There are numerous beliefs on how we
see the world generally. In positivist paradigms, however, ontology concentrates on the
autonomy of the social happening of different elements. Thus the world is one and there is
no other recognition. While the accentuation of interpretive paradigms is that the world has
distinctive implications regarding societal phenomena. This implies the adjustment in one
variable may influence the adjustment in the social setting itself, and along these lines
distinctive exploration can achieve diverse conclusions from the similar observation. On the
other hand Critical theory paradigms essentially perceive the world as something that has to
be changed. It involves the critique and altering social happening based on the interrogations
of the social happenings and individuals alike. In pragmatism, paradigms are not perceived
as “abstract entities with timeless characteristics” but rather, “paradigms are perceived as
ever changing belief systems” (Morgan, 2007, p.12).
Epistemological suppositions would be concerned with those approaches that recognize and
obtain knowledge (Bryman, 2001). In positivist paradigms, knowledge is the way to look at
the social world as one of the natural sciences. Theories are tried through experimental
methodologies. Theories would be objective through exploratory techniques. Results ought
to be unbiased through logical techniques. Generally the knowledge for interpretive
paradigms examines the phenomenon from multiple points of view. Additionally given that
the social setting is not the same as the natural sciences, the examination of social
phenomena can produce numerous elucidation. While in critical paradigms models,
knowledge is the consequence of practice. They are methods for doing research, as opposed
to methods for characterizing the ontology and epistemology underpinning research in this
case in the healthcare sector. This study used the paradigmatic stance of pragmatism as
reasoned out below.

57
3.2.1 Positivist Paradigm
Positivist paradigm concerns researchers who are attempting to look for or test the all-
inclusive laws about social phenomena. Supporters of this paradigm trust that the social
world is a world of natural phenomena. It believes that social reality, consisting attitudes,
convictions, practices and fulfilment can be measured equitably by utilizing traditional
scientific methods by impartial researchers. This paradigm utilizes the quantitative approach
and statistical analysis. Orlikowski and Baroudi (1991) suggest that for IS research to be
classified as positivist “there is evidence of formal propositions, quantifiable measures of
variables, hypothesis testing, and the drawing of inferences about a phenomenon from the
sample to a stated population” (p.5).
3.2.2 Interpretive Paradigm
Interpretive paradigm concerns researchers who are attempting to comprehend social
happening through individuals’ own experience and the meaning assigned thereafter (Myers,
1997; Klein and Myers, 1999) such as language, consciousness, common experiences,
publications, tools, and other artefacts (Walsham, 1995). Generally, the paradigm tries “to
understand the inter subjective meanings embedded in social life and hence to explain why
people act the way they do” (Gibbons, 1987: p. 3).
Crusaders of this paradigm contend that there is no earlier meaning of the independent and
dependent variables; however the attention is on the multifaceted nature of human sense
making as the situation rises (Kaplan and Maxwell, 1994). However, data is subjective and
therefore its clarification is fundamental. As such, the interpretive researchers are basically
using qualitative research approach to give a comprehension of the social and organizational
settings, based on building a complex, holistic picture, formed with texts, reporting detailed
views of respondents, and conducted in a natural setting (Creswell, 2013).
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3.2.3 Pragmatism Paradigm
Pragmatism deserts the old-fashioned perception that ontology and epistemology are
fundamentals upon which social scientific investigation should be based, because the
concepts of ontology and epistemology themselves have been empirically conceptualised
(Morgan, 2007). For pragmatists, the existence of so many types of ontologies (such as
realism, idealism and dualism) and epistemologies (such as interpretive, constructivist and
subjectivist) is evidence that they are ideals rather than objectively true concepts (Scott and
Briggs, 2004). Therefore, in pragmatism, paradigms are not seen as “abstract entities with
timeless characteristics” (Morgan, 2007, p.61). Rather, paradigms are perceived as ever
changing belief systems. They are means of doing research, rather than means of defining
the ontology and epistemology underpinning research in this case in the healthcare sector
(Kuhn, 1996; Morgan, 2007).
Methodologies are therefore not controlled by ontologies and epistemologies, so qualitative,
quantitative or mixed methodologies are allowed because all act as tools for empirical
inquiry. The pragmatic approach hence moves away from the theoretical starting point for
research. It instead endorses the utilization of the methodologies that are the most
appropriate for answering the research questions and addressing the phenomenon under
study. The focus is on generating knowledge for problem solving, and whether the
knowledge generated is useful for practice (Corbin and Strauss, 2008).
An ideology rejected by pragmatists is that of an Archimedean platform, that is an objective
or context free claim to scientific ‘truth’ (Dewey, 1917). Similarly, the 'spectator theory of
knowledge’, which suggests there is a world ready to be discovered by a passive observer, is
not accepted. Pragmatists therefore argue that absolute objectivity and certainty cannot be
59
attained in research. Rather, ‘truth’ is what is known at the time as provisional consensus
that is developed about the research topic, which later evidence could show is flawed or
wrong (Maxcy, 2003; Scott and Briggs, 2009). Related to the rejection of certainty,
pragmatism also postulates that everything that is known is affected by a certain level of
subjectivity. Knowledge discovered through empirical inquiry is inextricably connected to
the construction of knowledge in the human mind (Bryant, 2009).
However, pragmatist understanding of reality entails two theoretically and
methodologically significant consequences: not only is pragmatism one among a number of
‘philosophies of the flux’ (Dewey, 1917) but it also defines reality as being made by and
experienced only through human activity. Concisely: reality is nowhere else but inactive
experience, i.e. in action. “Reality in itself, or in its uninterpreted nakedness, is a
pragmatically meaningless notion, for it is a notion” (Dewey, 1917.p.22). Additionally
Dimitri Shalin provides us a notable picture of the pragmatist perspective on reality as
“Pragmatist philosophy conveys an image of the world brimming with
indeterminacy, pregnant with possibilities, waiting to be completed and
rationalized. The fact that the world out there is ‘still’ in the making does not
augur its final completion at some future point: the state of indeterminacy
endemic to reality cannot be terminated once and for all. It can be alleviated only
partially, in concrete situations, and with the help of a thinking agent. The latter
has the power to carve out an object, to convert an indeterminate situation into a
determinate one, because he is an active being” (Shalin, 1986: 10).
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Critics of pragmatism may say that one cannot distinguish beliefs that are useful but true
from those that are useful but false, because there is no suggested way of knowing absolute
truth. Scott and Briggs (2009) argue that it is immaterial whether something is true or false
because if a community trust something to be 'true', this will govern their behaviour
irrespective of how it compares to an inaccessible objective truth. The belief that is seized
and acted upon by people is much more important, and this is what may be found via
pragmatic inquiry. Brewer and Hunter, (1989) observes that pragmatist research emphasis
on whatever works to meet the particular needs of the researcher instead of restricting the
researcher to explicit methods in answering the inquiry question. It allows the researcher to
use the most suitable method (multiple methods) to understand the problem being
investigated. In addition Glaser (2001) emphasizes that a method’s choice is to be guided by
the needs of the research, rather than by any one paradigmic bias “My bias is clear, but this
does not mean I rubber stamp ‘ok’ or indite any method. The difference in perspectives will
just help any one researcher decide what method to use that suits his/her needs within the
research context and its goals for research” ( p. 2).
3.2.4 Grounded Theory and Pragmatism
Straussian Grounded Theory style was selected over other investigative methodologies
(Corbin and Strauss, 2008). The researcher used GTM to explore issues that influence
implementation of e-health in the healthcare sector in Kenya. With GTM, the purpose was to
develop a theory that has real-world application (Denzin, 2007). The reason behind GTM
begins from pragmatism and typical interactionism, a school of believers that imagines that
an individual does not respond to someone else's deeds, but rather the meanings they
61
themselves ascribe to the other individual's behaviour. Strauss and Corbin (1998) also
advocate that qualitative and quantitative approaches are only instruments in creating
valuable theories, and that one mode does not have pre-eminence over the other. They
express that “researchers in human and social sciences are operational pragmatists. The
more flexibly scientists work or are allowed to work, the more creative their research is apt
to be” (p.30).
Grounded Theory was selected principally in light of its intuitive plea. To begin this
contention it is basic to note that GT is not confined to any particular area, discipline or any
type of data (Bryant, 2009). GT has educated differing zones and has exhibited a broad
cluster of appropriateness (Morse, 2009). By and large Myers (2009) contended that GT has
an “intuitive appeal” (p. 111) for researchers since it licenses them to get “drenched” (p.
111) “deeply within the data”. This drenching is demonstrated for all intents and purposes in
the constant comparison, coding and memoing ways to deal with data processing. Charmaz
(2006) upheld this idea and attests that GT furnishes new researchers with the required
doctrines and “heuristic gadgets” to “get started, stay involved, and finish the project” (p. 2).
Charmaz (2006) concluded that while other qualitative methodologies allow researchers to
regard data as they wish without clear headings on the most proficient method to continue,
GT gives “explicit guidelines” (p. 3) which guide researchers about how to carry out their
study. For several pragmatic researchers, GT is very beneficial in answering their questions
Bryant, (2007), enlightening their thoughts and for providing them with guarantee when
hesitations arise during the exploration process in this instance exploring e-health
implementation issues in the health care sector in less empowered countries.
62
Besides GT has the ability to conceptualize. GT is special in its capacity to create ideas by
utilization of the rationale of steady analysis and regular memo writing (Bryant, 2009). This
particular way to deal with theory development is coming about because of the incessant
interplay amid data collection and analysis (Myers, 1997). Strauss & Corbin (1994, p. 39)
contended that “ideas have widening power” and are “simpler to recollect” as they include
“a myriad of incidents, which facilitates the transferability of these concepts into unfamiliar
contexts”. Moreover, Strauss & Corbin (1994) included that there is “much incentive in the
conceptualizing and conceptual ordering of research data” (p. 39). Remotely Strauss &
Corbin (1998) emphasized a comparative position reflected in their announcement, “by far
the most exciting use of GT over the last ten years is its legitimation of concept generation”
(p. 133). In any case Strauss and Corbin (1994, p. 274) recognized that “the major difference
between this methodology GT and other approaches to qualitative research was its emphasis
on theory development”.
Finally GT has a systematic style to data analysis. A noteworthy benefit of the GT method is
in its organized approach to data analysis. Stern, (1994) defined GT as “systematic
generating of theory from data that itself is systematically obtained from social research” (p.
2). Strauss and Corbin (1998) reflected this definition in their statement that GT is “a
qualitative research method that uses a systematized set of procedures to develop and
inductively derive GT about a phenomenon” (p. 24). Other qualitative research methods
“frequently depend on the use of broad principles rather than the systematic approach,
leading to difficulty in their application and interpretation” (Myers, 2009, p.9). This logical
approach of analyzing data is helpful in judging, generalizing and comparing the results of
GT research (Bryant, 2009). They contend that this logical approach to data analysis
provides for rigor and ensures credibility in the evolving theory. The theory, which is
63
grounded in the data, therefore forms a beginning for further research to extend current
knowledge, allowing substantive theories to become more formal theories, meaning they can
be useful to wider population. A supposition about the world made by Clarke (2009) is that
it involves a multitude of elements that intermingle in complex and unexpected ways.
Charmaz (2006) reinforced this argument by distinguishing between accidental discovery
(serendipity) and systematic investigation that is based on the epistemological and
ontological assumptions of the researcher. The latter is sustainable as it is a “broad-ranging,
purposive, systematic, prearranged undertaking” (p. 4), during which researchers
enthusiastically and purposefully place themselves in a position to look for “discoveries” (p.
4) instead of “continuing their usual research and waiting for the aha moments or
serendipity to strike” (Charmaz 2006, p.4). Furthermore Charmaz (2006) emphasised that
logical procedures such as simultaneous gathering and examination of data and the constant
comparative logic and theory that arises from data provide GT with rigor that is not
available in other qualitative methodologies. Additionally, Myers (2009), observes that
“being systematic provides the researchers with enough evidence to support their findings”
(p. 111).
Goulding, (1999) stretched this thought further by directing the researcher to check for the
relevance, fit, workability and modifiability of the discovered GT which enticed researchers
and kept them engaged. Moreover Charmaz (2006) added that “by adopting GT methods
you can direct, manage, and streamline your data collection and, moreover, construct an
original analysis of your data” (p.2). Besides, Corbin & Strauss (2015) notes that “method
facilitates the generation of theories of process, sequence, and change pertaining to
organizations, technology, positions, and social” (p. 27).
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3.3 Research Design
Research designs are typically grouped as either quantitative or qualitative (Creswell, 2013).
According to Neuman (2011) the quantitative approach is referred to as the scientific
empirical tradition technique, while the qualitative approach is alluded to as the naturalistic
phenomenological technique. Thus given that the focus is unlike, the use of these two
methodologies depends to a greater degree on the research paradigm, the underlying
assumption of the researcher and the type of the issue being contemplated (Gelo et al.,
2008). In other words, the qualitative approach generally tries to describe the scope of study,
the advancement of a measurement tool and develop hypothesis applicable to it, whereas the
quantitative approach typically tries to test the measurement tool and hypotheses. This study
espoused an exploratory case study with grounded theory methodology to examine elements
that are pertinent to successful implementation of e-health systems in the healthcare sector
as justified below.
3.3.1 Qualitative Approach
The qualitative approach concentrates on the compilation and analysis of non-numerical
data. In any case, the quality of this approach originates from its open-ended and regularly
its subjective nature, particularly with regards to analysis (Maxwell, 2010). Largely, this
approach endeavours to construct and widen further comprehension of the views,
encounters, and feelings of people or groups that may take part in specific practices inside
the natural setting in which it happens.
65
Normally, this approach has a tendency to be natural as opposed to being numerical, where
it covers the understanding of social phenomenon in its genuine settings of where to
concentrate on the implications given by people or gatherings about it (Denzin and Lincoln,
2011). Similarly, Creswell (2013) depicts a qualitative approach as “an inquiry process of
understanding based on distinct methodological traditions of inquiry that explore a social or
human problem. The researcher builds a complex, holistic picture, analyzes words, reports
detailed views of information, and conducts the study in a natural setting” (p.15).
In spite of the fact that this approach is associated to few members (e.g. people, gatherings
or associations), it gives an insight and comprehensive understanding of complex
phenomenon, for example, implementation of e-health in the healthcare sector through a mix
of different techniques to get data, for example, in-depth interviews and document analysis.
The results of this approach generally appear in narrative form. Case studies, action research
and grounded theory, among others, are typical qualitative research methods. There has been
a general tendency for researchers to utilize qualitative approach rather than the quantitative
approach particularly in IS research (Orlikowski, 1993; Korpela, 2011; Neuman, 2011).
This argument has been further supported by Mintzberg, (1979),
“measuring in real organizational terms means first of all getting out, into real
organizations. Questionnaires often won’t do. Nor will laboratory simulations.
The qualitative research designs, on the other hand, permit the researcher to get
close to the data, to know well all the individuals involved and record what they
do and say” ( p. 586).
66
In practice, IS research is not restricted just to address the technological aspect, but rather
goes past that to incorporate relationship with the organization, individuals or group who are
assisted by such systems (Avgerou, 2001). This argument is consistent with Neuman,
(2011), who demonstrates that Information System is comprised of a technological sub-
system and other behavioral sub-system. Additionally he adds that the relation between
these two sub-frameworks is the cause of what is referred to as IS phenomenon, thus
qualitative approach is best appropriate for IS research and specifically appropriate for this
study of exploring e-health implementation issues in the healthcare sector. Heath and
Cowley (2004) observes that qualitative research utilizing GT is a “cognitive process and
that each individual has a different cognitive style. A person’s way of thinking, and
explanation of analysis, may seem crystal clear to someone with a similar cognitive style
and very confusing to another person whose approach is different” (p.149).
Howell (2013) observes that the choice of the research design is always a complex task for
the researcher who must be aware of “what is the relationship between the world thought the
researcher, the researched and the issue under investigation?” (p.14). Thus the research
design used for this study was a qualitative approach focusing on grounded theory approach
methodology. This is because of its capability of conceptual thinking and theory building
rather than theory or hypothesis testing (Charmaz, 2011), which is typically done in
quantitative research approach.
3.3.2 Quantitative Approach
In contrast to qualitative approach, quantitative approach is a logical methodology in light of
the collection and analysis of data in numerical format. Positivist and objectivist
suppositions are the explanation behind researchers who utilize such an approach. This
approach is appropriate for research which intends to answer questions how much', what
67
number of', how routinely', and to what extent' (Masters, 2006), and what's more looking at
frequencies and rates of answers. By definition, the quantitative approach is apprehensive
with the gathering and analysis of numerical data, and frequently offered in diagrams, charts
or tables. However, such data can be analysed using statistical methods. Notwithstanding the
above, such an approach requires sufficiently enormous samples to be illustrative of the
whole populace, so that the outcomes can be duplicated, generalised or used in a
comparative way (Gelo et al., 2008).
In practice, the approach is concerned with giving quantitative depiction of the factors of the
research, where the researcher decides the relations between the factors of importance for
the study, and after that plans and tests hypothesis generated from theories which may along
these lines be evaluated either for approval or dismissal in light of a similar and measurable
analysis. Subsequently, the quantitative approach has a tendency to have deductive thinking
tendency. Interestingly, numerous researchers perceive that the utilization of quantitative
approaches adversely influences the capacity of individuals to think, articulate opinions,
clarify their encounters, and to react to the changes around them (Yin, 2014). Besides unlike
qualitative approach, the quantitative approach may disregard detail and profundity in
individuals' conduct, attitudes and motives.
3.3.3 Grounded Theory Methodology
GT methodology permits researchers to produce theories from the empirical data. Hence this
suggests as opposed to sourcing the data on the problem being studied through the
previously established inclinations of the researchers, which are frequently not far reaching,
the approach was able to gather the data straight from the natural setting of the problem
under study (Bryant, 2002; Fernández, 2005). Accordingly, the researcher decided to utilize
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the approach to investigate the issues that influence the e-health implementation in
healthcare sector in Kenya. Moreover, encoding as one of the styles that symbolize this
approach assisted the researcher to manage the intricacy of the distinctive unstructured
social settings (Bryman, 2001), and thus, helped the researcher to tackle the enormous data
gathered, theoretically and methodically formulate the theory.
GT contrasts from other qualitative approaches, as it permits the “development of theories
directly from the raw data, data collection and analysis in a systematic manner, and
maintains the data to be grounded, rather than forcing data to fit with current theories thus
fostering creativity” (Chamaz, 2014, p. 8). GT does not start with testing an existing
hypothesis, but utilizes the empirical data to produce concepts and theories (Fernandez et al,
2013). Typically, not bias emergence the theory with a priori assumptions. To determine this
development, researchers are urged to keep away from “preconceived hypothetical data”
(Myers 2009, p. 108), a suggestion that can be viewed as leverage to improve innovativeness
and activate the improvement of new thoughts. Besides, GT urges the researchers to
progress through a procedure of disclosure whereby themes and clarifications actually rise
out of the data. In essence, GT permits the researcher to get significance from the data and
analysis utilizing imaginative, inductive procedures. This permits for the appearance of
original findings from the data (Charmaz, 2006). Strauss and Corbin (1994) recognized that
“the major difference between this methodology GT and other approaches to qualitative
research was its emphasis on theory development” (p.278).
Furthermore GT has an inexhaustible data profundity and fortune. The approach utilized by
grounded scholars to gather abundant data is another advantage (Charmaz, 2006). Plentiful
data will make the “world appear anew” (Charmaz, 2006, p. 14) on the grounds that the
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abundance of the data will furnish the researcher with tangible and thick texture to build an
orderly analysis of the data notwithstanding helping the researcher to go underneath the
surface of the respondents’ social and subjective life (Charmaz, 2006). Similarly Geertz,
(1973) adds that GT helps with collecting “rich, thick data” (p.10). Charmaz (2006) suggests
that the exploration experience begins with “finding data” (p. 14). Data will uncover the
unique situation and structure of the respondent’s lives notwithstanding disclosing their
sentiments, perspectives, aims and activities (Charmaz, 2006). The specific end goal is to
acquire rich data, researchers are relied upon to look for thick descriptions (Corbin and
Strauss (2008) through scripting “extensive field notes of observation” (Charmaz, 2006, p.
14), “gathering thorough narratives from interviews” (p. 14).
GT approaches give the tools for “making sense of the data” (p. 15) and refining it to
“generate insight” into the phenomenon. Rich data will give the analyst adequate foundation
about the phenomenon under review. In addition, rich data will “reveal what lies beneath the
surface” (p. 19) and uncover any progressions after some time. Moreover, rich information
will empower the examiner to create analytic categories that encourages the examination of
data so as to permeate new thoughts. Indeed Charmaz (2006) espoused that GT can be
developed with various types of data relying upon the investigation theme and inquiries. The
researchers point is to enter the respondents' lives to see it from inside which in the long run
illuminates the “unobtainable views” (Charmaz, 2006, p. 24) that outsiders usually assume
about the world. Using the rationale of GT strengths makes the researcher to backpedal to
the data and forward into analysis to accumulate immense data and to refine the “emerging
theoretical framework” (p. 23) which provides the researcher a “fresh look and creating
novel categories and concepts” (p. 33). The inductive approach depends on the researcher
methodically “collecting, coding, categorizing and analyzing data” (p.19) to determine the
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theory that clarifies the phenomenon in this instance implementation of e-health in the
healthcare sector in Kenya. This study used Straussian style of grounded theory due to its
prescriptive edicts than the Glaserian style which is more emergent in nature.
3.4 Population and Sampling
The target population represents the sample elements that a researcher is interested in and
the group about which conclusions are drawn (Cooper et al, 2002). Neuman (2011, p. 240)
defines a sample as “a small set of cases a researcher selects from a large pool and
generalizes to the population”. The target population constituted key stakeholders from the
healthcare sector who are involved in the implementation of e-health systems.
Qualitative researchers have endorsed sample sizes ranging from as few as six respondents
to as many as 30 for a grounded theory study (Creswell, 2014). Sample design refers to
selecting respondents from the entire target population of the study. This is a well selected
group that represents the target population. GT utilises a form of purposive sampling, known
as theoretical sampling, where respondents chosen have the capability to provide the
researcher with abundant information on the issue being explored. Theoretical sampling is a
vital part of the grounded theory approach as it guides the researcher what to gather next
(Charmaz, 2006).
Glaser and Strauss (1967, p.45) defines theoretical sampling as “the process of data
collection for generating theory whereby the analyst jointly collects, codes, and analyses his
data and decides what data to collect next and where to find them, in order to develop his
theory as it emerges”. Similar definition of theoretical sampling has been reported by
Strauss and Corbin (1998, p. 202) as
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“theoretical sampling rather than being predetermined before beginning the
research, evolves during the process. It is based on concepts that emerged from
analysis and that appear to have relevance to the evolving theory. The aim of
theoretical sampling is to maximize opportunities to compare events, incidents,
or happenings to determine how a category varies in terms of its properties and
dimensions”.
Fundamentally adequate theoretical sampling is significant for production of diverse and
extensive range of theory. Furthermore inadequate theoretical sampling can result to theory
development process that is weak, thin and not well integrated base of theory (Amsteus,
2014).
Likewise the significance of theoretical sampling is further elaborated by (Charmaz, 2014)
that it plays a vital role in gathering pertinent data that is important in the process of
development of the theory. Additionally it plays a vital role in refining theory development
process and the theory by itself by directing the researcher towards pertinent data and this
data gathering process continues until and unless new data stop appearing. This was initiated
by interviewing significant individuals in the healthcare docket. This included key
stakeholders from healthcare industry who are directly involved in ICT implementation in
the sector. These individuals were drawn from the government, NGO’s, donors and private
sector. Additional participants were selected as the study progressed, emerging concepts,
relationships and theoretical relevance guided the researcher’s inquiry into additional data
sources based on whether they allow development or comparison of concepts (Goulding,
1999). The reader can take note that most of the respondents at the county, sub county and
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faith based hospitals were mainly system analysts. This was because the IT department in
these various institutions is headed by systems analyst. In addition the IT department falls
under administrative service which is a unit and not autonomous department on its own.
3.5 Data Collection
Data collection instruments and procedures refer to a process in which the tools of data
collection are identified (Creswell, 2014). This study used both primary and secondary data
sources. Thus to obtain primary data the researcher used open ended interviews. Primary
data collection began with interviewing key stakeholders in the healthcare sector that are
mainly concerned with the implementation of the systems. Open ended in-depth interviews
were used to collect data about the factors that affect implementation of e-health systems. As
Glaser (1992) pointed out, that grounded theory is “a general methodology of analysis
linked with data collection that uses a systematically applied set of methods to generate an
inductive theory about a substantive area” (p. 16). The GT approach can use any type of
data. Mostly it is up to the researcher to figure out what data to gather. All kinds of data can
be the building blocks of GTM such as field notes, interviews, audio recordings,
observations, and secondary sources. The kind of data the researcher pursues depends on the
topic and accessible available data as Strauss& Corbin (2000) summarises it in a few words
“all is data” (p. 276).
Accordingly, the researcher resorted to the utilization of open ended in depths interviews to
be able to collect “rich, thick data” (Geertz, 1973, p. 10) on the problem being studied in a
style that allows inductively develop theory to elucidate the problem itself (Charmaz, 2000).
Yin (2014) describes the interview as the most important source of evidence in exploratory
studies research. This is supported by Bryman (2001) who describes the benefits of open
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ended interviews that they provide a unique opportunity to uncover rich and complex
information from an individual. In this particular study of exploring e-health implementation
issues in the healthcare sector in Kenya, thus it was appropriate as the main source of
evidence backed up by secondary sources. The line of questioning was rather fluid pursuing
a conversational rather than structured questioning. Although the researcher prepared an
interview guide, the questions were asked from the consistent line of inquiry with a fluid
rather than rigid stream of questions. This unstructured method of questioning permitted the
respondents to narrate the story that elaborates their experiences.
The interviews were then recorded and transcribed. Secondary sources used included
government documents, journal articles on e-health and sessional papers presented in
conferences. In GT data gathering and analysis occurred in parallel. The transcripts and the
documents were keyed into NVivo version 11 software for analysis. The data collection
builded around the emerging and narrowing scope of the study until theoretical saturation
was achieved where no new data changes the emergent constructs (Charmaz 2000, 2006).
Corbin & Strauss (2015) indicate that theoretical saturation means “that no additional data
are being found whereby the researcher can develop the properties of the category” (p.61).
Theoretical saturation was attained by the constant comparison of occurrences in the data to
elicit the properties and facets of each category or code. Indeed Riley (1996) noted that
majority of the studies attain saturation with between eight and 24 interviews, depending on
the topic under exploration. In this particular study saturation was attained with 22
interviews. However the researcher went further to interview 8 other respondents to total to
30 respondents. The researcher was hoping that new data concepts would emerge but the
findings were just a replication of what the previous 22 respondents had said.
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3.6 Reliability
Reliability refers to the internal consistency of a scale, which looks at the degree to which
items are homogeneous. Typically it refers to the degree to which measurements are
accurate and repeatable. It is mainly concerned with the interrelationship among items in the
scale for all who answer the item (Fernández et al., 2013). In this instance the researcher
followed rigorous and relevant research practices, one can draw on several qualitative
strategies to ensure trustworthiness of a study. Reliability was tested using triangulation
strategy (Denzin, 2007). Triangulation was embedded into grounded theory and in this study
particularly. It was used by conducting interviews across the multiple participants regarding
the same issue and also by comparing emerging concepts and categories with existing
concepts and categories in the literature (Mays & Pope, 1995).
3.7 Validity
Validity in a grounded theory study was guided by four indicators: fit, relevance, work and
modifiability (Strauss & Corbin, 1998; Cresswell, 2001; Charmaz, 2001). Fit looks at
whether the theory fits the substantive area in which it will be utilized. The researcher was
exceptionally quick to generate concepts and categories from the gathered data. The
researcher considered the theory suitable for IS field, particularly e-health frameworks, as
the empirical data gathered amid this review was the principle basis for the advancement of
a complete comprehension of the elements that influence the implementation of e-health
frameworks in the healthcare segment in Kenya.
Pertinence or relevance, addresses issues concerned whether non-experts that are concerned
with the substantive field comprehend the theory (Mays and Pope, 2000). The researcher
was extremely quick to present the theory in a lucid and comprehensible way, particularly
for those individuals in a similar field of IT implementation in general and e-health systems
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implementation specifically. Moreover, the researcher was cautious throughout the analysis
procedure to accomplish the following: 1) the concepts and categories rising ought to show
some relationship, 2) the conceptual connections among concepts and categories ought to be
properly developed to the point of formation of the theory 3) there ought to be a thickness
and saturation of the concepts and categories emanating from the research process
(Fernández et al., 2013). The researcher was dedicated to see that the theory and the
outcomes are satisfactory and mirror the level of profundity and completeness of the study.
Work in terms of the demonstrative ability of the theory to explain how the problem is
solved, that is the theory works when it can interpret, explicate and envisage what is
happening in the substantive field. Furthermore can the theory be applied to a wide variety
of settings in the substantive area of study, in this case all e-health applications (Guba &
Lincoln, 1989). Modifiability looks at the theory’s capability of permitting the user some
degree of control over the structure and process of daily situations as they change through
the study. For instance does the theory allow the user some control as Glaser and Strauss,
(1967) puts it that does the “structure and process of daily situations as they change through
time?” (p.237). Moreover if the theory can be changed when new pertinent data is compared
to existing data. The research process was scrutinised to ensure new relevant data was
accommodated and managed to explain the phenomenon being studied. This was done by
allowing categories to emerge and constant comparison of categories (Charmaz, 2006).
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3.8 Data Analysis
Data analysis involves analysing text, developing themes and finally stating the meaning of
the findings, a result that this study achieved with regard to analyzing the interviews and
developing concepts and categories. Strauss suggests that “the focus of data analysis is not
merely collecting or ordering a mass of data, but organizing many ideas which have
emerged from analysis of the data” (1987, pp. 22). Grounded theory coding technique that
includes open, axial and selective coding was employed.
Glaser defines coding as “conceptualizing data by constant comparison of incident with
incident, and incident with concept” (1992, p.38). Fundamentally coding is the process of
separating data into particular units of significance for analysis and from that point
deliberately re-assessing them for their connections enabling the researcher to move the data
to a more elevated amount of abstraction. Open coding gave a good starting point to
recognize initial phenomenon.
Open coding depicted the explanatory process through which ideas are recognized and their
properties and dimensions are found in data. It is the piece of analysis that relates
particularly to the naming and categorising of issue under exploration through close analysis
of the data. Throughout open coding the data are separated into discrete parts, closely
examined, and analyzed for similarities and differences, and questions are asked about the
problem under study as reflected in the data (Corbin and Strauss, 2000). The researcher
matched occurrence to occurrence with the aim of building up the fundamental consistency
and its varying conditions (Allan, 2003). Occasions, happenings, objects and actions/
interactions that were observed to be reasonably comparative in nature or related in
significance were assembled under more unique concepts termed "categories" (Suddaby,
2006).
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The second phase is axial coding and it aims to add depth and structure to existing
categories. Axial coding reassembled the data that has been broken into separate codes by
open coding. Axial coding includes re-assembling the data in new styles by building up
connections amongst categories and their subcategories. It is named "axial" on the grounds
that coding happens around the hub of a category, connecting categories at the level of
properties and dimensions (Strauss and Corbin, 2000). Axial codes more often correspond to
categories that depict the open codes. The researcher keeps on coding and compares the
concept to more occurrences (Goulding, 1999). The process led to discovery of patterns and
themes in the data, showing the how the factors are related and their significance to the
study. This guided in coming up with a model for e-health implementation in the healthcare
sector in Kenya (Denzin, 2007).
The last coding stage is more dynamic than axial coding referred to as selective coding. The
purpose of selective coding is to coordinate and refine the classes into a theory, which
represents the problem being examined (Bryant, 2007) and validates the statements of
associations among concepts, and fills in any categories in need of further enhancement. In
selective coding the researcher lessens data from many cases into concepts and sets of
relational statements that can be utilized to clarify, in a general sense, what is happening in
the field of e-health implementation in Kenya (Simmons, 2011).
There are various software’s that are used for analysis of unstructured data. They include
MAXQDA, QDA miner, ATLAS, NVivo, CAQDAS among others. NVivo software version
11 was used to analyse the data. The purpose of NVivo software was to help the researcher
uncover and systematically analyze complex phenomena hidden in unstructured data. The
software allowed the researcher to group, sort and organize data; look at connections in the
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data; and combine analysis with linking, shaping, searching and modelling. It allowed the
researcher recognize patterns and interrogate data in a number of ways by utilizing its web
crawler and query functions. NVivo software has been utilized for detailed analysis in the
previous decade, among IS researchers (Orlikowski, 1993; Bryant, 2002; Njihia and Merali,
2013; Charmaz, 2014). The research objectives for the study were addressed by identifying
factors and their relationship that were relevant to successful implementation of e-health
systems thereby developed a comprehensive e-health implementation framework for Kenya.
3.9 Ethical Considerations
There was a critical necessity to discover general principles of ethics when carrying out
research on people. However, according to Trochim (2006), the way towards discovering
basic ethical principles to suit every study is greatly complex on the premise that there is a
specific setting for each study, which contrasts from other studies. With regards to this
study, for instance, a number of ethical principles were applied, for example, guaranteeing
the discretion of data, giving the respondents the opportunity to choose to be part of or not
part of the study, and show the data as it is with no change or misrepresentation. There was
additionally an elucidation of the goals to be accomplished in the study, and how the
healthcare segment can benefit from the outcome of this research. Likewise, individual
differences among the respondents were considered by providing a chance for all to take
part at different potentials and capabilities in the research (Mauthner et. al, 2002).
The researcher was cautious not to exert undue pressure on respondents to respond to
questions, yet turned to giving respondents the opportunity to answer inquiries for which
they wish to reply, and leave those they would prefer not to answer them. The researcher
additionally decided not to burden the respondents, in turn, there was a schedule for each
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meeting to be settled upon ahead of time with every respondent separately (Bryman et. al,
2011). The researcher was cautious not to put the respondents in humiliating circumstances,
for instance, the researcher avoided presenting subjects with content that might be sensitive
to the respondents. Additionally an atmosphere of trust was created from the starting point
between the researcher and the respondents in order to accomplish the desired goals of this
study.
3.10 Chapter Summary
This chapter has dealt with the research approach of this thesis. A brief introduction of the
research philosophy was discussed. Quantitative and qualitative methods have been
presented, paying particular attention to grounded theory methodology. The data collection
methods, sampling, and target population were discussed. Finally, the data analysis method
is presented. Grounded theory methodology was found to be most suitable for this study as
the researcher was able to dig deeper into the issues that hinder e-health implementation in
detail. This would not have been accomplished if the researcher had adopted a deductive
style of theory testing as many of these theories force a certain preconceptions unlike GT
that allows theory to emerge from data. GT utilises a meticulously applied set of methods to
generate an inductive theory about the substantive area. Thus it provided the researcher with
a deeper understanding of the healthcare sector in developing countries and as such provided
a basis for future scholars. The theory emerged gradually from the data collected and the
researcher was able to develop a data driven framework that was grounded from data
explaining e-health implementation issues.
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CHAPTER FOUR
DATA ANALYSIS AND INTERPRETATION
4.1 Introduction
This chapter discusses data analysis, and interpretation. The review of the various thematic
analysis and categories from each unit of analysis are described showing a brief overview of
all categories in each unit of analysis. The findings from the various data sources are
integrated throughout during the development of codes and the categories. A comprehensive
discussion of the findings is commenced in the next chapter. A total number of 30
respondents were interviewed. These were the key stakeholders in the healthcare sector that
deal with e-health implementation in Kenya.
4.2 The Data Analysis Process
Before advancing to the coding and analysis of the data, all the audiotaped interviews were
transcribed. Each interview script had an edge to allow the researcher to scribal analytical
notes. These transcripts were then keyed in to Nvivo software version 11 for analysis.
Consequently this was followed by coding of the data. This is changing patterns from a
group of experimental markers into data contents. From the speculative associations
between conceptual codes (their classes and properties) came from the data, an abstraction
of theoretical type was done, supported by data (Strauss, & Corbin, 2015). The procedure
started with preparatory analysis of the research context. This was followed by open coding,
where the researcher inspects the data in each conceivable way, examining the content line-
by-line and attempting to recognize noteworthy codes (occurrences) with a receptive
outlook, expecting to create categories and their properties from a cautious examination of
the constituent occurrences of the data. The texts of the interviews were completely
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examined, line by line and broken into sections or occurrences. At the point when the texts
were perused, inquiries were asked: Does this data allude to the issue under review? What
does this occurrence illustrate? What is going on? What did the interviewees mean? The
codes were then sorted consistently as per their properties, similarities and contrasts, at
levels signifying facets they are associated with.
Consequently the codes were assembled into components, components into subcategories
and subcategories into classes or categories. To improve the developing classes or categories
that were entirely identified with e-health implementation, the procedure of open coding was
delimited. Axial coding constrained the researcher to code just the events that related
fundamentally to the central category, so that the theory can be concocted (Kearney, 2007).
The process of delineating occurred at two levels: axial and selective. Alterations,
amendments of logical order, elaboration of property points of interest, eradication of
unessential properties, and joining of properties were altogether performed for this study. In
the meantime, a procedure of diminishment was done, since there was a level of consistency
among the original categories, allowing the development of the theory with several
concepts. At the second and third level of description, a decrease in the list of the
components and subcategories was established to be important to complete data gathering
and coding (Bryant, 2009). Axial coding shapes new associations and translates them into
important ideas and defines the first character of the theory (Denzin, 2007). The axial codes
were chosen as they arose from the data and were viewed as significant and valuable to
incorporate the components, subcategories and categories; and subsequently, to expand the
evolving theory.
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Likewise memo writing throughout data gathering is essential in theory development. These
are the documents of thoughts, through composed records, about codes and their relations,
taking concepts that originated from the data examination to the utmost level of
simplification (Strauss & Corbin, 2007). Thus when the researcher expounds memos,
“they raise the data to conceptual levels, develop the properties of each category,
elaborate relations about connections between categories and their properties,
begin to integrate these connections in category groups and relate the emerging
theory with other potentially relevant theories” (Glaser, 2009. p.91).
Undoubtedly the orderly construction of memos together with analytic ideas that were
assembled and found (Clarke, 2009), made it less difficult to articulate the theory and attach
the properties of the substantial codes through theoretical codes. Once theoretical saturation
of the categories was achieved, processes of adjustment, arrangement and amalgamation of
the memos related to the categories followed. Generally the content of the memos make up
the rationale of GT methodology, (Bryant, 2009) their arrangement is the key to explain the
theory for a textual demonstration.
In GTM, literature is thought to be another source of data the researcher can utilize to and
fuse into the theory, through the comparative analysis method (Martin, 2006). An expansive
literature review was done as the exploration was being done, intending to conform to the
needs of data analysis from the interviews. The literature additionally assisted in creation of
the framework, separating properties of categories, and in the definition of the codes
(Amsteus, 2014). The explanation of these developing categories, as a whole and in their
connections, exposed the category that was central to all other subcategories in this instance
the implementation of e-health systems. This core category is equal to what is referred as the
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basic social process, a demonstration of associations among the numerous categories of
analysis (Kelle, 2007). According to Strauss & Corbin, (1990) core category is “the central
phenomenon around which all the other categories are related” (p.116). This argument is
further elaborated by Glaser, (2009 p. 33) “the core category has the prime function of
integrating the theory and rendering the theory dense and saturated as the relationships
increase” (p. 33).
The core category fused 13 different subcategories that characterized the factors that affect
e-health implementation. These categories originated from the data. The model was
developed and its constituent components represented by the 13 interrelated explanatory
subcategories and central category. The structuring foundations of the theoretical model
were considered as questions supported each category of analysis. This was a lead to venture
into the field of e-health implementation in the healthcare sector in developing countries,
particularly Kenya, and they additionally add to the building and addition of studies about e-
health implementation in the healthcare sector in developing countries.
4.2.1 Open Coding
The researcher started analysis of the interviews using open coding. Charmaz (2006, p.19)
contends that “openness in the initial coding helps researchers to explore and allow new
ideas to emerge”. At this stage, the interviews were analysed and coded using the segments
word by word and line by line. These sections of the analysis were later called the
occurrences (Matavire, 2011). Normally, the occurrences can be derived from the slogan,
sentence, or more, but irregularly in as many words as paragraph (Clarke, 2009). The
occurrences were contrasted with different occurrences in the data to be gathered keeping in
mind the end goal was to get the codes. The researcher was trying to recognize activity verbs
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for each bit of the data, and afterwards gave it the code utilizing words to demonstrate these
activity verbs (Charmaz, 2014). For instance, in this occurrence the respondent expressed
that "concern is to have e-health system that can offer improved healthcare services, saves
time, cuts costs, are reliable and available all the time” (C7).
This occurrence incorporates these activity verbs: “having”, “offering”, “improving”,
“saving-time” and “cost cutting”. Subsequently this was then followed by analysis of codes
and gathering those related with related subjects jointly to give high order similarities known
as concepts (Lings, 2005). Afterwards these concepts were assembled to give higher order
similarities called categories. Nevertheless, these categories targeted to decrease the number
of concepts that will be utilized in successive analysis, as well as availing a fairly powerful
conceptual foundation of the subjects developed (Fernandez, 2013).
Consequently initial categories started to appear after several interviews. As indicated by
Urquhart, (2013), this procedure is alluded to as the constant comparison, which is a
significant component of the GT approach. The initial concepts and categories were equated
with other segments of the data to establish their theoretical relevance (Goulding, 1999;
Strauss, & Corbin, 2007; Charmaz, 2012). Consequently, the researcher exhibited a few
cases of the coding process and how initial codes, concepts and categories were created from
the respondents’ transcripts and were embraced as the reason for the successive analysis.
The following table shows an example of some key points which were obtained from the
interviews as well as occurrences that were distinguished and given a code in this instance
quality of e-health systems. The reader may take note that the researcher has used the
category of quality of e-health systems as an example of demonstrating how the other 12
categories were developed throughout the document.
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Table 4.1 Quality of e-health Systems
ID Incidents
C3 I hope the e-health systems can be available 24 hours
C1 It important that the systems are easily accessible from any
institution
C4 In addition the service response time is necessary
C2 I hope that e-health systems allows us to track all the patients
history
C15 There is need develop more organisation context focused system
C6 There is a necessity to provide immediate online support to
system users
C7 It is important to ensure that there is security of the information
assured over the network
C11 I hope the systems are scalable to accommodate future growth
and diverse data processing needs
C27 It is important for the systems to support communication among
all the stakeholders
C13 I hope the system will be reliable at all times when there is need
to consult
These occurrences were given the code: quality of e-health systems regularly
prompts changes in attitudes towards e-health implementation
The above incidents were assigned the code called quality of e-health systems. Quality of
the e-health systems influences user’s attitudes towards the usage which directly affects
implementation of the e-health. This may lead to user’s acceptance or rejection of the e-
health systems. Memos were written immediately after and continuously throughout data
collection so that they may perhaps be reviewed at any stage of this study. The researcher,
for instance, gave the conceptual name for the memo below as quality of e-health systems.
Accordingly, the memos were recorded as follows (Appendix III):

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Box 5.1 memo 1
Quality of e-health systems
There is an urgent need to improve healthcare services provided to all healthcare institutions in the
country. This can only be possible by harnessing ICT as a key enabler in enhancing healthcare
delivery. This consists of development of systems that the healthcare stakeholders can interact with
without problems. The system should be operable and user friendly at the same time accessible,
reliable, available and timely. However the implementation of such systems in the healthcare sector is a
tall order and requires the involvement of every stakeholder in the process. The stakeholders have a
certain minimum expectations of the quality of the e-health systems that they would meet their needs
accordingly.
At first, 158 concepts were generated in the research. Each of the concepts were coded by
sub-categories and their properties. These were then polished by an iterative correlation
analysis procedure of combining and marking, identifying similarities and contrasts amongst
them and further combining them into initial categories. The following is an illustration to
summarise the procedure of identifying and coding occurrences from the interviews for one
category, namely the quality of e-health systems. The Interviewees were allocated letter C
and numbers (1, 2, 3, and so forth..) referring to the number of each of the respondents. For
example, C3 implies respondent number 3 and what they said in connection to the nature of
quality of e-health systems category. Table 4.2 demonstrates the procedure of recognising
and coding occurrences from the interviews for one category for instance, namely the
quality of e-health systems.
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Table 4.2: Process Summary of Key Points, Incidents and Codes for the Quality of e-
Health Systems
ID Key points Open code
C3 I hope the e-health systems can be Availability of e-health systems and
available 24 hours applications
C1 Am hopeful that the systems can be easily Accessibility of e-health systems and
accessible from any institution applications
C4 Also, service response time is important. Responsiveness of e-health systems
and applications
C2 I hope that e-health systems allows us to Traceability of patients information
track all the patients history
C15 There is need develop more organisation Customised and contextualised
context focused system systems to meet the needs of the
institution
C6 There is a necessity to provide immediate Services with immediate Online
online support to users of the systems support when necessary
C17 Is the security of the information assured Ensure the data security and
over the network confidentiality is assured
C2 Is there adequate infrastructure for Have adequate infrastructure in place

everyone
C9 Are the systems user friendly. How easy is User friendly systems with ease to
it for any user to interact with the system use interfaces
without difficulty
C18 Are we able to share data with other Different institutions are able to
institution for better patients management Share data across the platform
C24 I hope the systems can be interoperable The modules need to be allow for
integration and Interoperability
C29 Are the systems well defined and Detailed services and Well defined
documentation attached for definition of supported by documentation
terms
C10 Is there backup for the data Back up mechanism to guard against
data loss
C11 I hope the systems are scalable to Ability to accommodate for future
accommodate future growth and diverse growth-scalability
data processing needs
C27 Its important for the systems to support Interactive services to enable
communication among all the stakeholders different stakeholders to
communicate easily
C23 I hope the system will be reliable at all The system should be available and
times when there is need to consult produce accurate results to enhance
decision making- reliability
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The researcher applied a similar procedure to generate other categories throughout the
document. Table 4.3 demonstrates the way concepts were created from labelled codes for
the quality of e-health systems category as an example.
Table 4.3: Diagrammatically the Emergence of the Quality of e-health Systems

Category
Labelled Codes Concepts
Availability of e-health systems , having e-health frameworks 24 Availability of e-health
hours a day, offering of e-health systems across various systems
departments without confinements, to provide all healthcare
institutions with e-health applications, experience appropriate e-
health services as prompt as you need them
Accessing e-health services, access to patients reports, prompt Accessibility of system
access to patients data and integrated modules, guarantee
important access to e-health services frameworks, guarantee
simpler reach to e-health frameworks, stakeholders access to all
e-health applications with ease, ease in mining of the patients
data
Quick reaction to e-health systems, willingness to help patients Responsive system
and patient’s care givers, providing prompt service, prompt
responsiveness , prompt response to querry searches and
feedback
Follow up of e-health services, checking before a transaction is Traceability of services
done and after, track our patients data over the network without
difficulty, to see exactly the service rendered, follow up
mechanism and continuity of care
To fit the specific health institution’s needs, adapting to changes Context -focused
in stakeholders needs, increment patients' qualities, focus on systems
specific request, contextualise to particular healthcare institution,
conveyed in light of patient’s needs, giving more context
centered services, reflecting desires of different stakeholders.
Offering online support to various e-health stakeholders, give Online service support
operational support, specialized online e-health services, keep up
with latest online e-health services, high quality and level of on-
line quality e-health services for transmission of patients data.
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Labelled Codes Concepts
Security of the data over the network, availability of controls and Security of the data
passwords, accuracy of the data, confidentiality of the data,
ethical values, electronic signatures, encryption of data, malware
protection, issues of cyber crime
Interoperability of the systems, integration of various modules in Interoperability and
the institutions, sharing of data among many health institutions. sharability
Have a standard that guides the sharing of data among
institutions
Organisation needs growth, data requirements grows, needs of Scalability
stakeholders change often. Inclusion of new modules to cater for
the growth, flexible modules
critical to distinguish and depict adequate terms of eache-health Well-defined services
system, portraying the meaning of the e-health frameworks,
contain subtle elements of how service are doing, a point by
point portrayal of the e-health services, comprehension of e-
health services, offering direction on the essential standards of e-
health frameworks
Empowering better correspondence with every one of the Interactive services
stakeholders and users, access to criticism without limitations,
encourage Knowledge sharing among different stakeholders,
provide for feedback mechanism
Its important for the e-health systems to be easy to use and learn, User friendly service
user friendly interface, easy to manipulate, easy to navigate, has
help button to assist users,
Every user needs to have the right hardware and software to use, Adequate infrastructure
availability of the internet and connectivity, updated software,
obsolete hardware, bandwidth, communication gadgets
Back up of the data is necessary to guard against losses, what Back up mechanism to
measure are put in place to back up the data for availability and protect the data from
future use, cloud services, secondary back up, external drives loss
virtualization, primary and secondary back ups
The system needs to meet the needs of users at all times without Reliability
experiencing major disruptions. The e-health systems need to be
reliable, meet the specific user requirements at all times
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As the researcher familiarised herself with the area, data was gathered selectively and it
concentrated on the developing classifications or categories. Taking after Corbin
and Strauss (2015) theoretical sampling was embraced where data was collected to elucidate
the classifications or categories, which when complete mirrored the interviewees 'encounters
and produced a comprehension of the phenomenon of e-health implementation.
A word tree showing the development of the quality of e-health systems category is shown
on Figure 4.1 as an example. Word trees are used in NVivo to search for words and phrases
in the document then visualize results in a tree like diagram. They show the context
surrounding categories from across the data and discover recurring themes and phrases that
surround a category of interest. The researcher used the same procedure throughout the
document to generate other word trees for other categories and formulate explore diagrams.
Responsive Interactive
User friendly
Accessible
Scalable
Traceable
Quality of
Online support
e-health Well defined
Systems
Available Context focused
Interoperable
Reliable
Figure 4.1: Word Tree on Quality of e-health Systems
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The following explore diagram (Figure 4.2) shows the diagrammatical development of
quality of e-health systems category for instance. The explore diagram lets the researcher
explore the connections between the concepts visually and how they relate to the central
category. In addition they are used to quickly and easily discover the relations that are
forming in the data as the researcher moves through the analysis. The researcher used the
same procedure to generate other explore diagrams for other categories throughout the
document.
Accessible Responsive
Available
Context focused
Online support Well defined
Quality of e-health
Reliable systems
Security and
Interactive
Ease of use
User friendly
Cost effective
Interoperable
Figure 4.2: Diagrammatical Emergence of the Quality of e-health Systems Category

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Consequently following Bryant, (2007) when the second phase of axial coding was
accomplished, using selective coding, the association between categories and their
properties were evaluated further in order to build up the theory. All the thirteen categories
were named and are introduced in Table 4.4 which were coded into the emergent categories
and their properties.
All emergent categories and their properties are summarised in Table 4.4
Table 4.4: Emergent Categories and their Properties
Emergent Category and the properties

Quality of e-health systems Benefits of e-health systems Macro political environment
superior and improved services, accurate diagnoses, Poor history of IT

available 24 hours a day, service accessibility, interoperability implementation in the
responsive time, more patients expert diagnosis, Increases healthcare sector, societal and
focused services, provide timeliness of treatment , economic development ,
immediate support when supports real-time treatment , foreign donor funds ,poor
necessary, reliability, user National planning for the partnership with private sector
friendly, interactive, population ,Empowered and public sector, lack of
interoperable, scalability, well citizens, Increased constant funding, low political
structured, well defined, productivity, efficiency and good will in sector,
accessibility, security, minimized costs, insufficient knowledge about
comprehensive services, service Governments becomes more e-health, embedded corruption,
improvement, prevail over the responsive to health needs, ROI is lower in healthcare
problem of interaction, data Equitable and accessible
sharing and integration, back up, healthcare to all citizens
save money, interactive
Systems integration Legal environment Socioeconomic environment
Lack of proper coordination Lack of an enabling legal Purchasing power, increased

between national and county environment for e- population growth, growing
government hospitals , transactions, obsolete set of digital divide, uneven
incompatibility, laws, weak legislations, distribution of resources,
reengineering of organisational absence of laws and rules generation gap, high poverty
operational procedures, absence concerning online sharing of levels, low literacy levels,
of standards to share data, patients data, inadequate e- ROI, demographic
interoperability problems, lack of laws for online transactions, characteristics, low income
synchronisation between lack of patient data security rate, sustainability. Equity and
systems, lack of integration of laws, lack of enforcement of access
donor funded systems and local the existing laws, penalties
systems lacking, lack of
accountability, liability
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Change process management Organisational efficiency Online safety and security
Absence of commitment for Lack of senior management Privacy and security, absence
change process, negative backing, poor innovative or weak system authorization,
perception of employees to orientation, absence of ICT security sensitization,
process, weak change procedure accountability in the inadequate training, alertness
planning, lack of participation in organisation, lack of public of Internet security, absence
change management procedure, private partnership, of intrusion detection systems,
inadequate resources for interdepartmental conflict, discretion of patients data,
facilitating the process, organisational bureaucracy, poor system audit, poor
resistance to the process, absence foreign donor projects, identification of users and
of campaigners and advocates in bureaucracy in the supply authentication, lack of access
the institutions to actualize the chain, Strategic orientation of control measures ,
process, lack of continuity plans, key stakeholders in the information safety, risk
lack of stakeholders involvement project, unrealistic assessment, data security,
in the design and development of expectation ,Lack of clarity network protection,
the system, complacent regarding specific costs, trust management complacency,
management, Disconnect issues, Conflict of interests, lack of tight security
between policy and organisational politics, self procedures.
implementation, lack of IS interests, management
leadership champion complacency,
Technology factors ICT competence Social Cultural factors
Interruption of internet, cost of Shortage of clinicians, Lack Lack of goodwill, fear

electronic services, inadequate of qualified technical team ,depersonalise healthcare,
human capacity for information ,Shortage of computer skills threat to patient privacy,
processing, poor national in health informatics among potential tool for interference,
telecommunication platform, health professionals , Lack of unemployment rate, poor e-
connectivity issues, inadequate computer training in health culture,
hardware and software. Presence professional curriculum, high tendency to self-negotiation
of out-dated technology, back up turnover of ICT personnel, and face to face
facilities, lack of standard, poor technically inadequate communication,
definition of users role, clients expertise. inclination to antisocial
have poor definition of behaviour, resistance,
specifications, lack of clear e- sabotage, staff ignorant ,
health policies in implementation corruption
e-Standards
lack of available standards, no

legislation exists, standards do
not address one unified area of
technology, conflicting and
overlapping standards, limited
participation in standards, lack of
importance of standards,
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4.2.2 Writing Memos
Essentially writing memos is a significant process for the researcher during the study. This is
where the researcher writes the notes and the ideas linked to the codes and their associations
which appear during the coding process (Martin, 2006). According to Charmaz (2000: p.
517), memo writing is
“the intermediate step between coding and writing the first draft of the
analysis, however, it helps to define leads for collecting data- both for further
initial coding and later theoretical sampling. Through memo writing, we
elaborate processes, assumptions, and actions that are subsumed under our
codes”.
Glaser (2001) accentuates the significance of the process by stating that “ignoring this
process through the transition to coding in order to sort or write may not be considered as
grounded theory” (p.83). Furthermore Glaser refers to memo writing as “the core stage in
the process of generating theory, the bedrock of theory generation” (p. 83). Primarily, the
use of the coding process for more than once led to overlapping and conflicting ideas that
were formed by the researcher on the issue being explored. This is consistent with the one
referred to by Strauss and Corbin (1990) that carrying out the coding process for more than
once may “generate conflict between the ideas”(p.27), thus the memos that were written
assisted in trailing ideas and concepts, and thus minimised the conflicts that may have
occurred during data gathering. Moreover, writing memos coincided with open coding of
data. This assisted the researcher to write down notes on the developing categories and
associations between them. Furthermore memo writing is critical as it facilitates reflection,
95
comprehension, and analytical insight of developing data and evolving theory of e-health
implementation. In this regard Charmaz (2006) pointed out on the importance of allowing a
free mind in memo writing “let your mind rove freely in, around, and from a category” (p.
81) until the theory emerges.
4.2.3 Axial Coding
The focus of open-coding was generating categories and their properties and determining
how the categories vary dimensionally. Axial-coding focuses on relating categories to their
subcategories at the level of properties and dimensions (Fernandez et.al, 2013) and noting
the dynamic interrelationships between categories to form the basis for theory building
(Goulding, 2009). Strauss and Corbin (2008) refer to axial coding “as a set of procedures
whereby data are put back together in new ways after open coding, by making connections
between categories” (p.26). The researcher accomplished this by the data gathering and
analysis, and memos that were made on an on-going basis amidst the study. In essence
Denzin (2007) notes that axial coding inspects the saturated categories and gives systematic
criteria to the researcher to aid in the improvement of connections between the categories,
properties and their significance to the literature.
At this stage the researcher sorted the data, weaving the broken pieces back together to
conceptualise associations between the suppositions derived through open coding (Bryant,
2007). In addition with the help of the literature and responses from the interviewees, the
researcher categorized the codes under more abstract higher-order concepts based on their
power to elucidate as well as reduce the number of units to work on while increasing the
analytic power (Clarke, 2009). Consequently once the researcher identified the concepts,
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their attributes were explored in depth, and their characteristics dimensionalised in terms of
their strength or weakness. The researcher laid out the properties of each category and their
facets. Thereafter the core category was then linked to its subcategories (Kearney, 2007).
Through statements about the nature of relationships among the various categories and their
subcategories, the researcher was able to form accurate and inclusive explanations. The
concepts under each category became its properties or explanatory descriptors. Further cues
in the data were searched to denote how major categories might relate to each other (Martin,
2006). Finally the data was subsumed into a core category which the researcher justified as
the basis for the emergent theory. Strauss & Corbin, (1990) refers to the core category as
“the central phenomenon around which all the other categories are related” (p.116). A core
category unites all the elements in order to provide an explanation of the behaviour under
study (Goulding, 1999).
At this level thirteen subcategories were generated from the open and axial coding process.
In addition, a single core category was reported frequently from the open and axial coding
process. The core category constitutes the connection to the emerging 13 sub-categories, and
consequently the reason for the phenomenon being explored. In this case the core category
was implementation of e-health systems in Kenya. Suddaby (2006) contends that the
categories rising up out of the initial phases of data gathering are preparatory and not
conclusive, while the later phase relies on upon more purposeful data to enhance and
reinforce the categories rising up out of the initial stage. Hence, the researcher familiarised
herself more with the research topic where she was able to decide if the data was significant
or not.
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The thirteen subcategories included the following: benefits of e-health systems, quality of e-
health systems, macro political environment, sociocultural environment, online safety and
security, e-standards, ICT competence, technology factors, change process management,
systems integration, organisational efficiency, legal and socioeconomic environment, while
the results of the axial coding improved and strengthened the categories. Consequently the
interviews were done until the researcher achieved the theoretical saturation point. As
indicated by Charmaz (2006: p. 95), theoretical saturation refers to “comparative analysis of
the data that is collected will continue until disclosure of all potential categories, the
impossibility of finding new themes in the data, and most importantly, validation of the
theory”. The table is a case delineating a part of the applicable occurrences that originated
from findings. It shows some of the occurrences that came from the category of quality of e-
health systems as an example. The same was applied to generate other categories in the
document.
Table 4.5: Occurrences arising for the Quality of e-health Systems
ID Occurrences
C3 I hope the e-health systems can be available 24 hours
C1 It is necessary that the systems are easily accessible from any
institution
C4 In addition service response time is essential
C2 I hope that e-health systems allows us to track all the patients history
C5 There is need develop more organisation context focused system
C6 There is a necessity to provide immediate online support to users of
the system
C17 It is important to ensure that there is security of the information
assured over the network
C11 I hope the systems are scalable to accommodate future growth and
diverse data processing needs
C12 It is important for the systems to support communication among all the
stakeholders
C23 I hope the system will be reliable at all times when there is need to
consult
These occurrences were assigned the code: quality of e-health systems often
leads to influencing users perception regarding e-health implementation
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Data gathering and analysis was done simultaneously which prompted a few changes to the
underlying categories. For instance, some underlying categories were changed to become
more distinctive, and additionally the emergence of new categories not alluded to initially.
Table 4.6 Changes made to the Initial Categories
Initial categories Final categories

Characteristics of e-health systems Quality of e-health systems
Importance of e-health systems Benefits of e-health systems
Political challenges Micro political environment
Social cultural challenges Social cultural environment
Social economic challenges Social economic environment
Security Online safety and security
Organisational change management Change process management
System integration challenges System integration
Organisational challenges Organisational efficiency
Laws and regulations Legal environment
Standards E-standards
IT capacity challenges ICT competence
Technological challenges Technological environment
Implementation of e-health systems Implementation of e-health systems
4.2.4 Selective Coding
Selective-coding is the process of integrating categories to build a theory and to refine the
theory (Urquhart, 2007). Its purpose is to relate categories found in axial-coding to a core
category which represents the main theme of research. Strauss & Corbin, (1990) explains
selective coding “as the process of selecting the central or core category, systematically
relating it to other categories, validating those relationships, and filling in categories that
need further refinement and development”(p.116). At this stage the researcher sought to
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integrate and develop the theory by creating relationship among the categories. Thus it was
necessary to create a conditional and consequential framework as supported by Denzin,
(2007) “analytic device to stimulate analysts thinking about relationships between micro and
macro conditions both to each other and to the process” (p. 461). The framework helped the
researcher to tell the story as narrated by the respondents showing the categories and their
attributes and how they relate to the core category and how they affect the implementation
of e-health systems.
The researcher used explore diagrams, word trees and review of memos to discover the
central category and its relationship with the other sub categories. The process started after
some categories had been discovered in axial-coding and continued with modification and
refinement until a theoretical saturation was achieved (Matavire, 2011; Fernandez, 2013).
After each step of coding (open-axial-selective), the researcher developed the multiple
layers of categorized theoretical statements that became hypotheses for gathering data
related to the statements. This was done during the subsequent step (Charmaz, 2011). This
helped the researcher to decide the data that will be the focal point of conversation in the
consequent interview, so the emphasis was on the researcher to identify appropriate
respondents for giving such data significance to the theory that will be produced. This
incursive process only stopped when no further modification was done and the theory was
validated (Amsteus, 2014). The process continued by trimming off excess and filling in
poorly developed categories until they were saturated. This was done through further
theoretical sampling where the researcher was able to come up with well thought-out
propositions for a theory on the comprehension process of implementation of e-health
frameworks in Kenya.
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From this discussion, the researcher was in quest to build up an applied model for
understanding the implementation of e-health frameworks from various viewpoints in the
healthcare arena. In spite of the accessibility of several options that can add in giving helpful
information about this issue being explored, the researcher was cautious to select the most
suitable and best able to supply information about concepts and categories rising from axial
coding process, together with suggestions made by interviewees to the researcher to do so
(Simmons, 2011; Charmaz, 2014). At this stage the thirteen sub categories generated in
open and axial coding were assembled into 5 key points of view, in particular the political
e-readiness, managerial practices, IS Capability, societal e-readiness and regulatory
framework viewpoint, as the amalgamation of these viewpoints affects the achievement of
implementation of e-health frameworks in Kenya.
The thirteen sub-categories that were recognized from the analysis of transcripts of the
interviews are described in detail in the 13 subsections below. However the reader can take
note that some responses are repeated severally, which contributed to the surfacing of other
categories. The purpose behind this was that some of the reactions included more than one
denotation and thus being considered would help the researcher get to more detailed
exploration on the issue being explored that is implementation of e-health systems in Kenya.
The results were presented by giving instances of the reactions of those who were
interviewed, where the reader can see how the evolving categories and concepts were
grounded in the data and how they were a replication of the data that was gathered. The
categories, including key concepts or attributes, were highlighted in detail regarding the
interrelationships between them to conclude with the research model for this study.
101
Similarly the reader can take note that there is a variation in the distribution of the number of
attributes defining each category. These variations emanated from the responses of the
interviewees where the researcher had no control over the respondents narrations about
certain matters as pertaining to e-health implementation.
4.3 Quality of e-health Systems
Various concepts identified with the quality of e-health systems were recognized from the
reactions. These include: availability, accessibility, responsiveness, traceability, context -
focused, well-defined, interoperable, online support, user friendly, reliable, security, well-
structured, and interactivity. These ideas are depicted in Figure 4.3, where the shape of a
rectangle stands for the name of the category, while the oval shape stands for the concepts or
attributes that were gathered from the data with the end goal of generating this category. In
addition, the direction of the arrow indicates the direction of the relationship between cause
and effect, as this category has an effect on the decision to implement e-health systems. The
rectangle figure stands for the core category, which is the objective related with the issue
that was being explored that is implementation of e-health systems. The same was used to
generate and elucidate other categories throughout the document.
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Responsive
Accessible Context focused
Well defined
Available
Online support Actual use

Quality of e- Implementati
of the
health systems Influences on of e-health Influences
Reliable systems
systems
Interactive
User friendly
Cost effective
Ease of use
Interoperable
Security and
backups
Figure 4.3: Quality of e-health Systems Category has an influence on the
Implementation of e-health systems
The concepts that were identified demonstrated the quality elements of e-health systems.
The reactions came from those interviewed reflecting the degree of awareness about the
significance of making sure the quality of systems is a requirement for the successful
implementation e-health systems. The concepts, namely, availability, accessibility,
responsiveness, traceability, context -focused, well-defined, interoperable, online support,
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user friendly, reliable, security, well-structured, and interactivity presented a helpful model
to assist to describe, examine, and assess the extent to which they are meeting expected
quality standards for maximum utilisation of e-health systems. In addition the framework is
also a tool to establish whether the e-health systems achieve the most favourable utilisation
as a result of the designs. For instance, some respondents stated that the e-health systems
suffer from the lack of the concept of quality in the design of the systems which in turn
affect their usage as well as the implementation of e-health systems. The following are
extracts from the respondents in support of this argument:
“We are well aware that the quality of e-health services are not up to the level
of the dream of every user , but innovativeness may make the dream come
true” (C13).
“I believe that the starting point should be by seeking for alternatives to
existing policies to provide Kenyans with better and improved healthcare
services. However if the e-health system were to be operational they need to be
easily accessible and available at all times of need” (C2).
“Also, service response time is important for us especially in matters of dealing
with peoples lives” (C1).
“Despite the presence of a few systems in the institution we are yet to
experience a fully functioning e-health system. The expectations would be that
the systems would have be interoperable and well structured. This would go a
long way in the supporting data sharing among institutions” (C8).
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“Security is paramount when we talk about passing data over a network. Thus
there is need to have systems that protect the patient’s information so that
confidentiality is maintained as well as addressing issues of emerging security
solutions. Furthermore backup mechanism goes hand in hand with protection
of the data” (C9).
“Communication amongst various stakeholders is very key in enhancing
decision making. The systems need to be interactive to support this aspect”
(C5).
“Meeting user requirements are key to any success of the system. Thus it should
be customised to suit the particular context of the organisations need. In most
cases things are done the way round and in this case the system would be
bound to fail”(C6).
“The system should have its sufficient documentation to facilitate ease of use”
(C15).
“There should be online support that assists users in solving problems when
needed to do so. This helps in technical support during use of the systems”
(C7).
In the same context, other respondents were having mixed views about whether the quality
of e-health systems will affect implementation of e-health systems or not:
“we should not be discussing quality of the e-health systems first since these
systems do not exist in the first place as they exist in theory but not in practise.
Thus I feel that quality may not be a key issue to implementation of the systems
in this case” (C4).

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“I am not sure how quality of e-health systems would be related to its
implementation however the system needs to have user friendly interfaces for
easy navigation” (C3).
Essentially it was observable that there was an agreement on the significance of considering
the element of quality in the expected e-health systems to be used in every organisation.
Thus the researcher noted that the quality of e-health systems was among the success
indicators that may contribute towards effective implementation of e-health systems in
Kenya.
4.4 Benefits of e-health Systems
A number of concepts linked with the benefits of e-health systems were identified. These
include increased productivity, more accurate diagnosis, cost reduction, assists in national
planning, accessible and equitable healthcare, time saving, enhanced decision making,
efficiency and effectiveness, empowered citizens, and a responsive government. These
concepts are described in Figure 4.4.
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Efficiency
Enhanced decision
Effectiveness making
Empowered citizens-
healthier people
Time saving
Accurate diagnosis
Benefits of e- Implementat Actual
health systems ion of e- use of e-

Cost reduction
Influences Influences
health health
systems systems
National planning
Real time treatment
Equitable Accessible health care
healthcare
Figure 4.4: Benefits of e-health Systems has an influence on the Users Perception about
e-health Systems thus on the Implementation of the Systems
The concepts that were identified revealed the benefits of e-health systems which is crucial
in persuading users in accepting the e-health systems. Perceived usefulness among the users
plays a key role towards dealing with resistance of e-health systems. The reactions came
from those interviewed revealed the level of understanding about the benefits of e-health
systems. Acknowledging that they are aware of the benefits then this shows that they have
an idea of what hinders the effective implementation of e-health frameworks. Furthermore
this demonstrates that they appreciate what technology can do in improving healthcare
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management. The concepts, namely increased productivity, more accurate diagnosis, cost
reduction, assists in national planning, equitable healthcare, time saving, enhanced decision
making, efficiency and effectiveness, empowered citizens, provided a helpful model to aid
in describing, examining, and assessing the extent to which these benefits are directly or
indirectly affecting the utilisation of e-health systems and improving healthcare service
delivery. Additionally the model is a tool to establish whether the e-health systems are of
any significance to the organisation or a mere cost spending venture. Indeed the respondents
were in agreement that the e-health systems are more beneficial than manual systems thus
were eager to have working systems. The following are extracts from the respondents in
support of this argument:
“E-health is primarily application of ICT applications in healthcare delivery.
This would provide greater, and faster, access to a patient’s medical history,
reducing poor response to courses of treatment. This would result to a healthier
population” (C11).
“They would facilitate earlier - and more accurate - diagnoses. This would
reduce the morbidity and mortality patterns across the nation” (C1).
“It would improve interoperability between systems and data sharing among
institutions. This would help the government in planning for trends and patterns
of diseases” (C22).
“Allows rural residents to receive expert diagnosis and treatment from distant
medical centers especially through telemedicine” (C7).
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“Though the initial outlay is high on the other hand it Increases timeliness of
treatment while reducing medical costs” (C8).
“Sharing of data across institutions would support real-time treatment” (C10).
“The data available from the systems would support the government in National
planning for the population on trends and patterns of diseases” (C25).
“Since the patient websites will be available to the patients at large. That would
lead to a more empowered citizen managing their personal health” (C3).
“There will be increased productivity, efficiency while minimizing costs at the
same time” (C15).
“Governments will be tasked to become more responsive to health needs of the
population”(C6).
“It would lead to a more equitable and accessible healthcare to all citizens”
(C4).
“I feel that the use of health systems will save our money and time for both care
givers and the patients as well the organisation at large”(C29).
“Often I find it difficult to consult with my colleagues about management of difficult
cases along the practise but telemedicine for instance this would be made much
easier” (C14).
“Let me say am so tired with seeing the way manual processes dominate our health
facilities yet the financial institutions are almost paperless. Why can’t the same
happen in health surely” (C21).

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“I strongly feel e-health is the way to go in this era of improved patient care”(C21).
Nonetheless it was apparent that there was an agreement on the significance of
implementing e-health systems in Kenya. Fundamentally the responses above demonstrate
that the stakeholders appreciate the immense potential e-health systems have towards
improvement of healthcare delivery in the sector thus its usage is highly desirable. The
respondents were then asked about their experiences in e-health systems in their
organisation. The concept’s associated with this category included start up, minimal, read it
on paper, initial stages, more theoretical than practical. These were critical to helping the
researcher understand the level of implementation of e-health systems in the country. These
sentiments were echoed by a number of respondents in the following narrations
“The only contact I have had with e-health applications is only the use DHIS
which is a reporting tool for the organisation data” (C1).
“To be honest i have read very good papers about the benefits of e-health on
the internet but in this particular institution but the closed that we practise is
manual systems” (C9).
“E-health is not a new terminology as have been involved in the design of the
policies and strategies that are to be used” (C27).
“Yes I have interacted with electronic records management application for
management of patient’s records at the outpatient level” (C5).
“We have a donor funded system that is used to capture biodata for the patients
and used for compilation of statistics” (C21).

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“No idea of how e-health works practically just in theory from books” (C2).
“Its true we still at start up and dealing with many implementation challenges”
(C8).
“Most of the systems are still manual but attempts are being made to automate
patient’s records. So I would say we are at start up essentially but the journey
has begun” (C13).
“We are fairly advanced in technology with most of these e-health applications
being used in the institution however we do not share data with other health
facilities” (C23).
“let me be frank there too much talk about e-health systems and practically no
real application. Let our facilities get a little serious for once” (C24).
Thus it was clear that there was an agreement that the implementation of ICT in the
healthcare it’s still at start up with many of the respondents indicating that most processes
are still manual. Generally this is more prevalent in the case of public sector and faith based
institutions. This argument was supported by respondent (C13) in this category. In contrast,
there was a variation in the responses when it comes to the private sector that has interacted
with various applications of e-health in management of their patients. However these private
sector institutions do not have interoperable systems that can share data across all health
facilities in the country as indicated by respondent (C23). Typically they maintain their own
fragmented discrete systems that are not integrated with other healthcare institutions. This
demonstrates that e-health implementation is still a work in progress in the wider healthcare
sector today in Kenya.
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4.5 Macro Political Environment
A number of concepts related with the macro political environment were recognized from
the responses. These include: poor history of IT implementation in the healthcare sector,
social and economic development, foreign donor investments, poor collaboration with both
private and public sector, insufficient funding, conflicts of interest, low political goodwill in
sector, inadequate knowledge about e-health frameworks in the region, embedded
corruption, ROI is lower in healthcare than other sectors therefore entrepreneurs are
reluctant to invest in the sector. These concepts are described in Figure 4.5.
Corruption Foreign Donor

investments
Low Political good

will
Lower ROI of
IT investments
Implementat Actual
Macro political
Inadequate ion of e- use of the
funding
environment Influences Influences
health system
Policies and systems

strategies
Insufficient knowledge
of e-health
Poor collaboration
Economic
between partners
Conflict of development
interests
Figure 4.5: Macro Political Environment Category has an influence on the

Implementation of e-health Systems
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Largely these ideas that were generated mirrored the macro political impact that may have
an effect on the implementation of e-health frameworks. The reactions originated from those
met mirroring the level of mindfulness about the requirement for changes in the political
arena as a necessity for the effective implementation of e-health frameworks. The ideas,
specifically poor history of IT implementation in the healthcare sector, social and economic
development, foreign donor investments, poor collaboration with both the private and
public sector, inadequate funding, low political goodwill in sector, conflicts of interests,
insufficient knowledge about e-health systems in the region, embedded corruption, ROI is
lower in healthcare thus investors are hesitant to put resources into the segment gives a
valuable structure to help with distinguishing, investigating and assessing the development
of an enabling political environment where public and private organisations would cooperate
to booster e-health implementation frameworks. In addition the structure is additionally a
tool to decide if the macro political issues are sufficient enough to booster the
implementation of e-health systems, or not as well as assess if political goodwill would
support the implementation of e-health systems. For instance, some respondents stated that
the political stability is a key to implementation of IT, in healthcare sector. The following
are extracts from the respondents in support of this argument:
“However, political stability attracts foreign direct investments, particularly
investments in information technology” (C22).
“I agree that political stability has contributed greatly to the attracting foreign
investments in the country though little is felt in the healthcare sector” (C26).
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“Let me say that this bickering by the politician’s is not too good for the
country. The foreign investors are very cautious on investing in the country
especially in healthcare” (C11).
“No investor would be comfortable in investing in a country that has riots now
and then. The risks would be very high” (C8).
This may be attributed to among other things lack of solid economic impact of e-health in
the country. This is because the return on investment is lower in healthcare than other
sectors therefore entrepreneurs are very reluctant in investing in e-health systems.
“There is lack of clarity regarding specific cost benefit of e-health systems to
all stakeholders” (C13).
“Generally there is a perception of IT being viewed as a cost centre rather than
a strategic enabler” (C6).
“Let me say there are no direct benefits in investing in healthcare as opposed
to other sectors therefore the politicians would be reluctant in supporting
health project” (C3).
Some respondents stated that one of significant challenges facing the implementation of IT,
in healthcare is the lack of good political will. This is demonstrated by lack of commitment
to the project by the political environment.
“Low political good will make the implementation of information technology
harder and harder” (C30).
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“There is no political goodwill to support the project which leads to poor
governance and leadership” (C25).
“It is not easy for politicians, wherever they are to break the bureaucratic
barriers because they think they will lose a lot of the tasks entrusted to them”
(C12).
“I agree with politicians it is about self gain first then the country gains later,
e-health may not give them a mileage that may translate into votes thus they
may have slackness in supporting the e-health project per see” (C4).
“Unless something is benefitting the politicians directly then counting on their
support is expecting too much” (C16).
Similarly in the same perspective, others attributed the differences in political interests and
alignments to the unequal distribution of resources. In addition the politicians IT orientation
was cited as a barrier too. The respondents felt that these differences affected the political
goodwill to implement e-health systems in the sector:
“Not all politicians are eager to facilitate the implementation of information
technology in the healthcare sector; each one has a different agenda seeking to
it” (C27).
“Different agendas of politicians may be affected by their educational
background” (C4).
“Some of them have little knowledge on how technology can be applied in
healthcare therefore may be reluctant to support the e-health project” (C8).
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“Few of them fully understand how IS can be beneficial in healthcare” (C20).
“Differences in the political interests has an effect in resource allocation
especially when it is about electronic resources” (C3).
“The issue of resources allocation is among the factors that affect the decisions
of politicians in policy making” (C6).
Besides others felt there is an element of corruption where by the personal interest override
the public interest thus affecting implementation of the systems:
“There is an element of corruption where by there too many interested parties”
(C28).
“Most leaders are not motivated by the public gain but personal interest from
the project” (C5).
“Personal gain overrides the project gain” (C25).
“Many of them would be pushing for the tenders to be given to their preferred
affiliates thus may choose to sabotage the project especially where the friends
are not lucky in being awarded the tenders” (C25).
“I cannot agree more our leaders are guided by self gain what is in it for me.
How do I benefit first. Unfortunately in healthcare the benefits are minimal as it
does not translate into votes” (C18).
116
Consequently there was a consensus that the budgetary resources granted were not adequate
to ensure the implementation of the e-health in the sector and as such the sector has to rely
on donor funded projects on one hand. These projects come with their own conditional
clauses thus integration of these systems with various institutions becomes difficult;
“let me admit there are budgetary constraints, the government is willing but not
able. The available funds are given to priority areas whereas e-health is
considered a luxury than a necessity” (C6).
“The government relies on donor funded projects in the sector. These donors
are conditional projects that are meant to serve the needs of mother countries.
So most of these donors funded systems are unwilling to integrate with the local
systems to share data or even share their infrastructure with the local
institutions” (C14).
“There is poor coordination from development partners which results to many
fragmented systems that exist that are meant to serve certain donor driven
needs. Resources used to set up these systems would be helpful if there was
cooperation and coordination in the design and implementation of these
fragmented systems thereby reducing costs of infrastructure” (C2).
“The government lacks leverage when dealing with development partners
which leads to fragmented system. Because of financial reliance on the donors
the government is compelled to accept the donor conditions. The donors are
very reluctant to integrate their systems with the existing systems” (C7).
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“Most NGO’s’s are unwilling to work together or even share infrastructure
resources and funding because of the policies from mother countries” (C1).
“Since the government is constrained finance wise they have no option but
invite in donors who come up with conditional grant”(C9).
Whereas others felt there is poor coordination between national and county institutions
which creates a barrier in implementation of the systems
“There is poor coordination between National and county healthcare
institutions. As a result there is poor system mapping at both level of
governance” (C9).
“Most county healthcare facilities are unwilling to liase with the national
health facilities” (C11).
“The devolved structure has created mapping of countys which results in poor
coordination between the county health facilities and national hospitals as well.
This would affect system integration among all healthcare facilities” (C10).
“The devolved structure has resulted in minimal consultations among the
different tiers of government thus even sharing of data or expertise would be
difficult” (C7).
Lack of proper trust and cooperation between public and private institutions to share data
also featured significantly as a barrier to implementation of the systems;
“I think there is lack of proper trust and cooperation between public and
private institutions to share data” (C6).

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“There is need of setting up systems that can share data. for example in the
United States private hospitals such as John Hopkins Medical School reports
their workload to CDC unlike in Kenya where the private hospitals do not
report their data”(C6).
“The DHIS currently does not capture data from private hospitals which leads
to under reporting, poor interventions and policy formulation” (C11).
“This is because of absence of a law that exists to compel the institutions to
report the data or any penalty spelt in the law” (C4).
“I believe private hospitals are not special in any way. Why don’t they report
their data? Who should compel them to do so? In that case how can we achieve
system integration between all private and public healthcare facilities? Is this
achievable really, I truly doubt” (C23).
Accordingly it was observable that there was an agreement on the significance of having an
enabling political environment and political goodwill as a necessity for the successful
implementation of e-health frameworks. For instance, the majority of the responses
expressed that guaranteeing an enabling political environment is related with the following
concepts: political stability, support, willingness, goodwill, and evenly resource allocation.
Fundamentally based on the reactions, the researcher noticed that the improvement of
conducive macro political environment is amongst the important indicators for the
implementation of e-health frameworks in Kenya.
119
4.6 Socio Cultural Environment
A number of concepts linked to the socio cultural environment were recognized from the
responses. They include corruption, lack of goodwill among the clinicians, they view IT as
time consuming, they fear it will depersonalise healthcare, view that it is a threat to patient
privacy and a potential tool for interference in their practise, increased unemployment, lack
of e-culture, IT illiteracy, corruption, tendency to self negotiation and face to face
communication, inclination to antisocial behavior, tendency to resist and sabotage the
process, staff ignorance of what they want. These concepts are described in Figure 4.6.
Fear
Low good will
Sabotage among
clinicians
Threat to
privacy
Depersonalisat
ion
Social cultural Implementati

Unemployment Actual use
on of e-health of the
Influence Influences
environment systems
Corruption systems
Low staff
morale morale
Staff ignorance
Low e-health
Time wasting and
culture
High IT interference
illiteracy
Figure 4.6: Social Cultural Environment Category has an influence on the

120
The ideas that were acknowledged mirrored the social cultural factors that may affect the
implementation of e-health frameworks. The reactions originated from those interviewed
mirroring the level of mindfulness about the requirement for changes in the socio cultural
conditions as a prerequisite for the fruitful implementation of e-health frameworks. The
ideas generated specifically: corruption, lack of goodwill among the clinicians, they view IT
as time consuming, they fear it will depersonalise healthcare, a threat to patient privacy and
a potential tool for interference in their practise, increased unemployment rate, poor e-
culture , tendency to self negotiation and face to face communication, inclination to
antisocial behavior, tendency to resist and sabotage the process, staff ignorance gave a
helpful structure to help with distinguishing, breaking down and assessing the socio cultural
conditions that may influence e-health implementation. Furthermore the model is
additionally a tool to decide if the socio cultural setting is sufficient enough to affect the
implementation of e-health, or not. For example, some interviewees indicated that there was
presence of corruption in the institution, and e-health will just facilitate the problem further.
The following are extracts from the respondents in support of this argument:
“Even with e-health corruption will remain or probably increase because it has
become a culture nothing else in this society” (C29).
“Despite all the calls to eliminate the rampant corruption in the country,
solutions such e-health might be exploited to increase corruption and not
enhance patient management” (C9).
“I do not deny the existence of corruption in our institutions even with the
manual system so IT can only enhance it” (C3).
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“I have major concerns that there a likelihood that technology might just be
used to promote corruption instead of helping the patient” (C3).
Additionally others respondents said that they were afraid that technology would make them
loose social contact with their patients in the management of illness;
“I have my own reservations that technology will depersonalise healthcare and
more specifically will interfere with the rapport with the patient” (C16).
“Despite the benefits of e-health it has a likely hood of denying the caregiver
the social touch with the patients” (C8).
“I do not disagree that e-health is likely to make us disconnect socially with the
patient” (C4).
“I believe technology will make us loose social contact with our patients which
is very critical to their healing” (C29).
“Let me say patients care is holistic and social contact is primarily one aspect
of promoting faster and better care. Now with introduction of technology this
particular aspect might be obstructed. Most patients actually get better
immediately if they have one on one with the care giver” (C27).
A few others viewed e-health as an interference to their busy working life and therefore are
too busy to deal with it;
“I view e-health as being time consuming and an interruption in our busy
schedule” (C29).
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“It is generally a threat to patient privacy and confidentiality”(C25).
“It’s a potential tool for interfering with our practise” (C30).
“E-health may just be a waste of our practising time” (C29).
“In most cases these systems are always down thus wasting too much time”
(C3).
“Its easier to write on the manual file than the screen” (C23).
“I think it is good to concentrate on treating patients and not managing
technology which is our core mandate” (C2).
“I believe we do not have extra time to learn how to use technology as well as
treat patients”(C28).
Many agreed that there was fear of change which resulted in resistance to the technology as
they were afraid that IT would take over their jobs;
“Most people fear the interaction of technology” (C29).
“People do not feel comfortable in accepting change” (C5).
“I feel uncomfortable voicing disagreement about technology so I may just
sabotage it” (C4).
“People fear that technology may take over their jobs” (C3).
“We have always done things manually so how will technology help us” (C14).
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“I do not disagree that I have fear about what change portends to the
institution” (C14).
“Many agree that technology may replace their jobs so they might be hesitant
to support it” (C4).
In addition others indicated that the users expectations are not well defined thus meet their
expectations
“Users expectations are not always met which leads to resistance or sabotage”
(C20).
“We are not sure of want we want as users” (C28).
“The few applications that we have interacted with do not fully meet our needs
therefore we not sure how this could be addressed if e-health was to be
functional” (C28).
Besides others stated that they did not have the right training and skills to operate the e-
health system which might act as a barrier towards technology implementation;
“Most of us do not have an idea on how to go about navigating the systems”
(C27).
“I do not have the basic skills to operate the systems and so are my colleagues”
(C28).
“Most of us lack training in informatics as this was not embedded in the
curricula in college” (C7).
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“I believe we do not have all the time on earth to start learning new things
other than medicine”(C29).
“For instance how do I enrol for an IT course at this level now? It’s almost
impossible to be honest. Therefore the skills to operate the systems are lacking
and time for training is a factor” (C29).
Past experiences regarding the implementation of technology was mentioned as a hindrance
to the implementation as some respondents did not want a repeat of the previous
experiences.
“Previous attempts to automate the hospital failed, so I do not trust any
attempts of the same type” (C5).
“Lack of organisation commitment to real change was behind the failure of all
previous attempts” (C4).
“This may never work here in Kenya just in theory” (C7).
“I think the concern of the stakeholders should be how to make treatment
available to all and now introducing complicated technologies to us that may
never work” (C19).
“Is it another cash cow for eating some money” (C16).
Majority of the respondents were of the opinion that the implementation of e-health would
increase the proportion of unemployed people in Kenya. This argument is supported by the
following narration.
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“With technology we could easily be retrenched, and this is not fun” (C5).
“I think that the use of IT threatens opportunities for employment” (C7).
“Technology and unemployment are two sides of same coin” (C3).
Others viewed e-health as a threat to patient privacy thus expressed their reservations about
using it. This may be a barrier to implementation of e-health systems;
“How safe is the patient data over the network” (C24).
“Will confidentiality of the data be assured as we use these systems” (C17).
“I feel that the e-health will infringe on the privacy of the patient greatly”
(C22).
“Who is liable for the breach of confidentiality of the information?” (C2).
“I think use of e-health is good but security of data online needs to guaranteed”
(C2).
“Have you addressed the emerging technologies and security of data” (C8).
“I believe for health to be successful the stakeholders need to address issues of
cyber crime and security of patients data on the network. Without which users
will remain adamant on utilising the technology” (C8).
A number of the respondents indicated lack of goodwill among some stakeholders. In the
same context they said they can only agree to use the systems if they are assured that they
are working perfectly;
126
“We are not sure that these systems will work best for the interests of the
patients” (C10).
“I think we can only use the system if we are assured that they will work
perfect” (C1).
“I do not disagree that the system can only be effective if they work well for us”
(C6).
“I strongly feel that there is no good will among the top management in rolling
out the health systems. Thus it might be difficult for the junior staff to
completely accept the project if their seniors are reluctant towards its
implementation” (C17).
Necessity of having pilot programs for e-health was emphasised. These can be utilized to
impact skills to the users on the utilization of e-health systems:
“Why, then, can’t users have the opportunity to pilot the e-health systems
before it’s rolled out on a larger scale” (C12).
“Pilot projects would be the only way to buy users into accepting the
implementation of the system” (C12).
“Pilot projects would go along way in meeting the defined user’s needs thus
reducing the chances of sabotage from the users” (C4).
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“Pilot services may enhance the knowledge of users of the new system and
thereby increase the confidence towards the implementation and use of e-health
systems” (C1).
Subsequently there was an agreement on the significance of the socio cultural conditions in
affecting the implementation of e-health frameworks. According to majority of those
interviewed, socio cultural values, practices and norms influence the attitudes towards the
implementation of e-health systems. For example, the reactions concentrated on perceiving
technology as an interruption and a hindrance towards effective patient’s management.
Consequently based on the respondent’s reactions, the researcher noticed that the
improvement of sociocultural elements is among the significant indicators for the
implementation of e-health systems in Kenya.
4.7 Online Safety and Security
Various ideas related with the online safety and security was recognized from the reactions.
This included: privacy and protection, system authorization, security training, awareness of
Internet safety, intrusion detection, and confidentiality of patient’s data, system audit,
identification and authentication, access control, information security, risk assessment,
information assurance, internet safety, tight security procedures, management complacency.
These concepts are described in Figure 4.7.
128
Complacent
management
Internet safety
Information
assurance
Risk assessment
Actual
Data/
information use of the
security Online safety Implementati
and security on of e-health systems

Influences Influence
System audit
systems
Sensitization of
internet safety
Privacy
Protection
Controls
Authorization
Figure 4.7 Online safety and Security Category has an influence on the Implementation
of e-health Systems
Generally the ideas that were recognized mirrored the measures to guarantee the protection
and security of the patient’s data over the network. The reactions originated from those
interviewed mirroring the level of mindfulness about the significance of guaranteeing the
protection and security of the network as a prerequisite for the fruitful implementation of e-
health frameworks. The ideas, in particular the privacy and protection, system authorization,
security training, awareness of Internet safety, intrusion detection, confidentiality of
personal information, system audit, identification and authentication, access control,
information security, risk assessment, information assurance, internet safety, tight security
129
procedures, management complacency on investing on security systems provided a helpful
model to assist recognize, examine and assess the safety and security of the e-health
systems.
Likewise the e-framework is a tool to establish whether the e-health systems provide safety
and security measures for the patient information as well as protecting the users of the
system. For instance, interviewees expressed that the achievement of e-health relies
fundamentally on the dedication to execute protection measures and security of patient’s
data and exchanges over the network. The following are extracts from the respondents in
“However, the Internet does not contain enough safeguards to make me feel
comfortable when using it” (C4).
“However, the failure to ensure security and safety of the Internet will impact
the successful implementation and use of e-health at all levels” (C8).
“The first thing that comes to the minds of the users is whether the e-health
systems are secure or not” (C1).
“Thus the organisation needs to adopt tight security procedures to safeguard
the patient’s data on the network” (C7).
“There is need to apply the latest security techniques to ensure comfort of the
users of e-health systems” (C29).
“How is the confidentiality of data assured online?”(C1).
130
“Who is liable for its breach? Supposed the information is leaked to
unauthorised persons along the network. Who is liable?”(C15).
“There should be policies in place to protect patient’s data on the network
otherwise users will be hesitant to use the systems” (C24).
“In addition there should be penalties attached for breach of confidentiality of
data over the network” (C11).
“I think cyber crime is an emerging concern when it comes to transmission of
data over the network. This would need to be addressed if the e-health systems
were to be successful” (C1).
Some respondents highlighted the issue of the safety and security of e-health systems as one
of the elements of inculcating trust in use of e-health systems on the users on one hand and
the healthcare institutions on the other.
“Ensure the protection of online information guarantees the users trust in e-
health systems” (C11).
“Ensuring that online information and transactions are secure is important for
me to do so” (C2).
“Security and trust are two sides of one coin, whenever stated confidence,
security must be present” (C10).
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“Are there any safeguards put in place to ensure protection of users of the e-
The notion of guaranteeing the security of the data especially when sharing information was
highlighted. This is in instance where some had negative encounters with some few
institutions;
“Hoping that there is a commitment from the institutions not to use the data for
other purposes without prior permission” (C13).
“My experience with some institutions makes me afraid to be clear enough to
accept utilising the e-health systems” (C4).
“There must be specific controls on what information can flow among other
institutions” (C6).
“Also we believe that a policy outlining how the patient data will be used and
stored would make me comfortable utilising the system” (C28).
Whereas different respondents indicated the requirement for a strategy to guarantee threat
management as far as risk identification and evaluation thereby create a plan to deter future
risks;
“Thus, the institution should adopt tight security procedures to ensure the
protection of patient’s information over the network” (C7).
“Risk reduction is one of the priorities of e-health to increase public confidence
in the utilisation of the systems” (C8).
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“The institution has taken all the ways and means to ensure the management of
new systems where identified and assessed the potential risks through the plans
and strategies at all levels for successful implementation” (C19).
“The institution seeks to apply the latest security techniques to ensure the
comfort of users in utilising the e-health systems” (C24).
“There is need to create awareness and training about the risks required for all
users of the e-health systems” (C2).
“Symbols summarising what technical security measures are embedded in the
system would make me more comfortable utilising the systems” (C16).
Even so other respondents pointed on the issue of increasing the awareness and sensitization
of users about the security and protection measures when utilising the e-health systems:
“Therefore, it is important to train users on the Internet threats to avoid failure
in implementing e-health systems” (C8).
“Most of the security breaches resulting from the ignorance of users in the
basics of information security, thus training is very key” (C3).
“There is need to create passwords for users and sensitize them on the
importance of changing passwords regularly”C12).
“There is need to have abide information security standard ISO 27001 so that it
can protect the patients information on the network” (C9).
133
Ultimately there was a consensus on the significance of guaranteeing the protection and
security of the data while using e-health frameworks. Majority of the respondents
interviewed expressed their concerns on the protection measures and safety of patient’s data
over the Internet which may sway the confidence of users of e-health frameworks, and
subsequently influence the attitude towards the implementation of e-health frameworks.
Fundamentally the reactions were mainly on aspects of privacy, awareness and protection of
patient information on the network. Subsequently based on the respondent’s reactions, the
researcher noticed that guaranteeing the safety and security of the patient’s data on the
network and internet are key elements that are significant indicators for the implementation
of e-health systems in Kenya.
4.8 Technological Environment
Various ideas related with the improvement of ICT-related platform were recognized from
the reactions in particular: disruption of Internet service from time to time, cost of e- health
transactions, inadequate capacity for patient data processing, poor national ICT platform,
connectivity issues, lack of adequate hardware and software. Presence of out-dated
technology that may be non functional, back up facilities are lacking or obsolete, lack of
standard to guide implementation, poor definition of users role, clients have poor definition
of what hardware and software specifications they require, lack of clear e-health policies in
implementation. These concepts are described in Figure 4.8.
134
Connectivity Standards for
implementation
issues
E-health policies
Poor national ICT

infrastructure
Obsolete Actual
technology
use of
Technological Implementatio
the
Inadequate environment Influences n of e-health Influences
hardware and
software system
systems
Capacity for
information
processing
Affordability
Interruption of
internet service Poor Hardware
specifications
Poor definition
of user’s roles
Figure 4.8: Technological Environment Category has an influence on the

The concepts that were acknowledged demonstrated aspects of the improvement of ICT-
related framework that affect the fruitful implementation of e-health frameworks. The
reactions originated from those met mirroring the level of mindfulness about the
significance of creating an enabling ICT platform in the implementation e-health
frameworks. The concepts namely disruption of Internet service over time, costs of e-health
transactions, inadequate capacity for information processing, poor national ICT platform,
technology may be non functional, back up facilities are lacking or obsolete, lack of
standard to guide implementation, poor definition of users role, clients have poor definition
135
of what hardware and software specifications they require, lack of clear e-health they want
gave a helpful structure to help with distinguishing, breaking down and assessing the
technological factors that may influence e-health implementation. Ideally the model is a tool
to decide if an enabling ICT-platform is sufficient enough to support the implementation of
e-health, or not. For instance, respondents expressed that the improvement of ICT-related
platform positively affects the trust of the clients in the implementation of technological
resources, especially e-health systems. The following are extracts from the respondents in
“Inadequate ICT infrastructure makes me not excited about the idea of e-
health” (C3).
“Lack of advanced ICT infrastructure hampers the ability to utilise e-health
systems” (C8).
“No one denies the importance of ICT infrastructure in the successful
implementation and use of e-health systems, but is it available” (C4).
“The clients are not sure of the specifications of hardware and software needed
to run the systems” (C6).
In addition some said that the technology available is obsolete which may be non-functional
and unevenly distributed.
“Most of the hardware that we have is both outdated and malfunctional”(C8).
“If the computers are too slow to process basic ms office software what about
the e-health systems” (C2).
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“There is unequal distribution of the infrastructure generally. Compare the
rural facilities and the urban facilities” (C30).
“Some facilities especially in the rural set up do not have computers” (C21).
“Many of the ups are not functioning” (C21).
“The back up mechanism available is either lacking or obsolete” (C4).
“Though there is poor uptake of IT in healthcare even when it happens it
becomes obsolete very fast” (C9).
Equally other respondents highlighted that digital divide was a hindrance to
implementation of e-health where a few people have access to digital resources while
others did not have. This coupled with some having the knowledge to utilize the system
while other people did not have the basic knowledge to utilize the systems.
“alot of initiatives is needed to overcome the digital divide in this country)”
(C7).
“Compare the rural versus urban set up. The urban set up is more enlightened
and advantaged” (C7).
“The urban population are more advantaged when it comes to access and
equity of digital resources unlike the rural set up”(C8).
“More access points would be a good idea to solve accessibility problems in
the rural areas” (C8).
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Connectivity issues especially in the rural areas were cited as a hindrance to implementation.
“Faster Internet access speed is important for me to implement e-health
systems” (C19).
“Low penetration of broadband Internet access in the rural areas makes e-
health implementation difficult” (C19).
“There is a tendency to have frequent interruption of the internet connections
even in the urban areas” (C14).
“Whereas the connection charges are not cheap either. In a country where we
spend less than one dollar a day, it might be expensive for common citizens to
utilise the internet” (C14).
“Is internet affordable to all Kenyans who principally form the population of
our patients? Majority can only afford to provide for basic needs therefore
spending on the internet charges will be a tall order”(C10).
The issues of absence of clear policies that guide implementation emerged from some
respondents.
“There is an absence of clear guidelines to on how to implement e-health
systems” (C1).
“What guidelines are there for implementation of e-health” (C25).
“There are no policies in place to guide in the implementation of e-health
systems” (C8).
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“And even they exist are all the stakeholders aware or are they really followed.
I doubt very much” (C8).
Some respondents indicated there was a problem of performance and reliability of the ICT
platform, which affect the implementation of e-health systems:
“Interruption of internet services from time to time is normal and this shows the
lack of commitment by providers to facilitate the, implementation and use of e-
“The government lacks the continued implementation of programs to upgrade
the ICT infrastructure to ensure flexibility, reliability and availability of e-
“So that it can be argued that the quality of Internet services in the urban setup
may not be the level of those in urban setting” (C1).
“As usual, people who live in the towns, have a good coverage of the network
and therefore better services” (C1).
“I hope the government is working to develop the ICT infrastructure to cover
all parts of the region equitably” (C9).
Lack of the necessary ICT platform was cited as affecting the availability of the medical
equipment as affordability was an issue which may affect the implementation of e-health
systems,
139
“Most citizens find it difficult to acquire computer resources (hardware,
software and network services) necessary for utilizing the m-health which is an
application in e-health” (C23).
“Limited number of Internet providers reduces competition and keeps prices
high” (C17).
“High bundle or internet charges may not support e-health use” (C17).
Similarly others cited conflicts between users and implementers of the system
“Users are not aware what the new system will benefit them” (C6).
“Many of them are not electronically prepared to utilise the system” (C7).
Whereas some respondents expressed concerns that confidence in local solutions is lacking.
There is a tendency to rely on foreign solutions that may not necessary work locally,
“There is a tendency of hiring of foreign consultants with no experience in
systems implementation practically, they are more theory oriented” (C14).
“This often leads to poor design and analysis by the consultants where actual
needs of users are not met” (C1).
“The foreign consultants tend to be more preferred than local solutions; often
these solutions do not meet the needs of the local institution” (C17).
“The foreign are perceived to be more superior than our local solutions which
is not the case at most times” (C23).
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“There is a tendency of our local institutions of trusting what comes from the
west as being much better than what our local consultants can offer. Which is a
wrong notion as these foreign consultants almost always get it wrong” (C23).
There are poor system mapping at both national and county hospitals
“let me say most of the county staff have no clear definition of what
specification they expect from e-health systems” (C12).
“They are guided by the boundaries of the regions thus even sharing resources
is quite difficult” (C11).
“Telemedicine would be difficult for example as the counties do not share
expertise with other counties as well” (C26).
Therefore there was an agreement on the significance of building up a robust ICT platform
that provides the stage for supporting e-health frameworks. Majority of the respondents
acknowledged that the presence of a stable ICT platform affects the availability, access and
utilization of the e-health applications. Thus the researcher noticed that the improvement of
a stable ICT platform is amongst the key indicators for the implementation of e-health
systems in Kenya.
4.9 Change Process Management
Various ideas related with the change process management were acknowledged from the
reactions, in particular; commitment for change, attitude of employees for change, change
process management, champion to implement change, involvement for change, resources for
change, resistance to change, absence of advocates and supporters in the institutions to make
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the change, lack of continuity plans, lack of stakeholders involvement in the design and
development of the system, complacent management, lack of IS leadership champion. These
Complacent
management
IS leadership
lacking
Continuity plans
Absence of
advocates for Actual
change
use of
Change process Implementatio
n of e-health the
Resources for management Influences Influences
change
systems
systems
Attitude towards
change
Lack of
Commitment
Stakeholder’s
Management Champion for involvement
process change
Figure 4.9: Change Process Management Category has an influence on the

Evidently the ideas that were acknowledged mirrored the organisational aspects of the
change process management towards the implementation of e-health frameworks. The
reactions originated from those met mirroring the level of mindfulness about the
significance of dealing with the change process management at all levels to guarantee the
achievement of the implementation of e-health frameworks. The ideas commitment for
change, attitude of employees for change, change process management, champion to

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implement change, involvement for change, resources for change, resistance to change,
absence of advocates and supporters in the institutions to make the change, lack of
continuity plans, lack of stakeholders involvement in the design and development of the
system, complacent management, lack of IS leadership give a valuable system to help
recognize, break down and assess the parts of change process management, particularly e-
health in Kenya. Furthermore the structure is a tool to decide if the change process
management on the e-health frameworks is adequate to build confidence and thereafter the
effective implementation of e-health, or not. For instance, interviewees expressed that there
is thin connection between guaranteeing change process management towards e-health
systems and users trust, which converts into a positive attitude towards implementation of e-
health frameworks. The following are extracts from the respondents in support of this
argument:
“Change management is essential to restore the trust of users in utilising e-
health systems which translates into successful implementation of the same”
(C3).
“Change must begin from the institution, not from users” (C11).
“I do not blame the users if they do not accept the change towards e-health,
since the institution itself is reluctant to accept the idea of change” (C12).
“Commitment by senior management officials increases the confidence of users
and thus to influences implementation of e-health systems” (C5).
143
“I have made an observation that senior managements are not committed to
change process management. They are very unenthusiastic to the process”
(C16).
Some expressed that the processes of change management meet resistance, especially in
the initial phases. Much of this resistance is usually more prevalent amongst the elderly
as it is much more difficult for them to learn and adjust to new e-frameworks, for
example, e-health frameworks:
“There is resistance by the elderly for change within most organisations. May
it be clinical or administrative staff” (C12).
“Not necessarily, but we can change if we feel that there is prudent
management to take into account all the needs of all users in the process of
change” (C12).
“There is a tendency to resist change among the older users in the institution”
(C6).
Whereas other respondents were of the opinion that accomplishment of the change process
towards e-health implementation requires the support of everyone on the organisation
especially top management:
“Change must begin from the top management,” (C3).
“Change must begin from the organisations senior managers not users” (C3).
144
“The absence of advocates and supporters in the institution to make the change
could adversely affect the implementation of e-health systems” (C19).
A few respondents said that the achievement of the change process is associated with the
presence of viable approaches for correspondence between the different stakeholders, in
order to encourage the change towards accomplishing the implementation of e-health
systems;
“The institution does not involve users in decision-making related to the change
which negatively affects the trust of users and thus, implementation and use of
e-health systems” (C6).
“What we lack is the existence of effective communication between the
management and users to implement the policy change towards e-health”
(C12).
“Management in most times does not involve all the stakeholders in the change
process management” (C17).
Besides, others expressed concerns that there was no commitment for change process in the
institution. In essence there was no one championing for IS leadership
“The management is lethargic towards supporting the change process
management” (C3).
“There is no one in the institution to champion for the e-health project. Its
neither here nor there” (C5).
145
“I believe that there are no resources set aside for supporting the process
towards e-health implementation” (C7).
“There is an absence of advocates and supporters in the institutions to make
the change towards implementation of e-health” (C29).
Whereas a few said that the processes should go together with several training modules of e-
health systems so that various stakeholders can learn how to adapt and use the new
technology.
“People need to be trained to cope with the new system to deal with the
patients” (C11).
“Employees in most departments need adequate training to lead the change
towards e-health” (C14).
“My worry would be is the institution committed towards allocating resources
to support the process” (C27).
“I believe that management might be disinclined to allocate resources to
support the change process management” (C19).
Equally others were of the opinion that there is an absence of continuity plans of initiated
projects thus the project die at start up or immediately the initiator of the project is exits.
This then affects the success of the implementation;
“There is lack of continuity plans in place for initiated projects like e-health
systems” (C13).
146
“No proper plans are put in place to take over projects” (C22).
“A champion of the e-health project is lacking to give leadership” (C18).
Accordingly it was clear there was an understanding among the respondents on the
significance of dealing with the change process management towards e-health, which
positively affects the perception users have about e-health systems that in turn has an impact
on the implementation of e-health frameworks. Consequently the researcher noticed that
change process management is among the significant factors that may affect the
implementation of e-health systems in Kenya.
4.10 Systems Integration
A number of concepts related to the integration of systems were acknowledged from the
reactions. These included lack integration between national and county hospitals,
incompatibility, reengineering of organisation’s internal processes to support integration of
systems, lack of standardisation to share data, interoperability problems in systems, lack of
synchronisation between systems, lack of integration of donor funded systems and local
systems. These concepts are described in Figure 4.10
147
Integration btn donor
and other systems Poor system
design
Interoperability
issues
Lack of
standardization
Reengineering of
internal processes Implementat
for integration System Actual of
ion of e- the
integration Influences Influences
Integration btn
health systems
county and environment
national systems
systems
Incompatibility of
systems
Synchronisation
issues
Personal Conflict of
interests Interests
Figure 4.10: System Integration Category has an influence on the Implementation of e-

Health Systems
Largely the ideas that were acknowledged reflected aspects of integration of e-health
frameworks as crucial to e-health implementation. The reactions originated from those met
mirroring the level of mindfulness about the significance of amalgamation of health data
frameworks at all levels to guarantee the fruitful implementation of e-health frameworks.
The ideas, namely lack of integration between national and county hospitals,
incompatibility, reengineering of organisation’s internal processes to support integration,
lack of standardisation to exchange data, interoperability problems in systems, lack of
synchronisation between systems, lack of integration of donor funded systems and local
148
systems give a valuable structure to help recognize, examine and assess parts of the
integration of e-health systems in the sector. Basically the structure is necessary in deciding
if the frameworks are significant in the successful implementation of e-health, or not. For
instance, respondents expressed that there is absence of standardization to share information
amongst private and public organisation, which makes it rather hard to implement e-health
systems as private hospitals are not compelled to share data with public hospitals. These
sentiments were echoed by a number of respondents in the following narrations:
“There is no law that exists that compels the public and private sector to share
information” (C15).
“The private sectors are profit driven while the public sectors are service
driven” (C7).
“There are no policies that exist that guide on how institution can integrate and
share data” (C22).
“The private sector does not trust the public sector with sharing of their data”
(C23).
In addition others cited interoperability problems and compatibility issues among the
existing systems
“Its difficult to integrate modules within this institution” (C15).
“Most times the system are not compatible and integration is difficult” (C18).
“The users are reluctant to integrate the systems too” (C2).
149
“I think there are generic differences between the designers of the systems and
the users thus this makes interoperability difficult” (C6).
A number of the respondents said that there was need of having an explicit methodology of
how data is shared among institutions to promote trust-building among the players thus
facilitate successful implementation of e-health systems;
“I do not know how I can trust the e-health systems in the absence of a clear
methodology for the exchange of information” (C21).
“Despite all the claims of change, the methodology followed by some
institutions to manage the various information systems is still subject to
restrictions and not clear enough to ensure trust in the new system”(C3).
While some cited that there is lack of synchronisation between systems and clinical
workflow,
“Let me say that at times the systems are not synchronised with the clinical
workflow hence implementation may be difficult” (C30).
“The systems are not well designed to follow the clinician workflow hence
resistance creeps in” (C2).
“The systems and the clinical workflow do not speak the same” (C6).
Majority were of the consensus that there is lack of integration of donor funded systems and
local systems. This creates a big barrier towards implementation of e-health;
150
“The donor funded systems are not willing to integrate their systems with the
locally available systems. This would save the organisation time and money
even in sharing resources” (C3).
“The donor systems are there to meet specific needs of the donor thus very
unwilling to integrate their systems with the local ones” (C29).
“Donors have specific terms of operation and no law exist to compel them to
integrate their systems with local ones” (C16).
A few were of the opinion that there was a lack of coordination between national and county
government hospitals in integration of systems,
“The county hospitals and national hospitals have issues of trust when it comes
to sharing of information” (C22).
“Each institution tends to hoard their data for its own gain than share it thus
implementation of e-health might be a tall order” (C25).
“Most of these facilities will upload the workload data on the DHIS but not
share it among facilities” (C25)
Finally, some stated that before addressing the issue of integration of e-health systems, the
organisations should restructure their internal operations. This would ensure there is a
comprehensive and practical framework that supports effective e-health systems
implementation. Such a framework would promote sharing, processing and collection of
data across the healthcare field:
151
“There is a need for the institution to restructure internal government
processes before e-health is implemented” (C28).
“The current structures are complex and not clearly defined so it is difficult for
us to reform health sector without real restructuring of the internal processes
and procedures” (C16).
Consequently there was an agreement on the significance of integration of e-health
frameworks for effective e-health implementation. Majority of the interviewees
acknowledged integration of e-health systems among various institutions was very
significant in successful implementation of the systems. By and large the researcher noticed
that guaranteeing the integration of e-health frameworks is among the significant
components for implementation of e-health systems. Therefore the researcher observed that
absence of integration of e-health frameworks is among the significant issues that may
hinder the implementation of e-health systems in Kenya.
4.11 Organizational Efficiency
Various concepts related to organisational efficiency were recognized from the reactions.
They specifically include; senior management support, lack of innovative orientation, lack
of accountability within the organisation, lack of public private partnership, bureaucracy,
strategic orientation, organisational politics, self interests, lack of IS leadership, unrealistic
expectation, trust issues, conflict of interests.. These concepts are described in Figure 4.11;
152
Conflict of
Lack of all
interests
IS leadership stakeholder
lacking participation
Complacent
management
Unrealistic
expectation
Actual
Strategic
orientation
Implementatio use of
Organisational
Top management Influence n of e-health Influences the

efficiency
support
systems system
Self interest
Innovativeness
orientation
Accountability
Trust issues
Absence of Public
private partnership Bureaucratic
procedures
Figure 4.11: Organisational Efficiency Category has an influence on the

Primarily the concepts that were generated reflected aspects of organisational efficiency
needed to boost implementation of e-health frameworks. The reactions originated from those
met mirroring the level of mindfulness about the significance of guaranteeing the effective
organisational practices and procedures that guarantee the fruitful implementation of e-
health frameworks. The concepts include: senior management support, lack of innovative
orientation, lack of accountability within public, lack of public private partnership,
bureaucracy, politics, Strategic orientation, unrealistic expectation, trust issues, lack of
153
stakeholders participation, lack of IS leadership, conflict of interests, self- interests present a
helpful model to assist recognize, examine and assess the viability of elements of
organizational efficiency towards e-health implementation in Kenya.
Basically the structure is important in deciding if the organisational efficiency is
sufficiently viable to build trust among the clients, and along these lines the fruitful
implementation of e-health, or not. For example, some interviewees expressed that the
absence of adequate support from senior management in the organisation may not provide
an official status of e-health systems and consequently this may adversely influence the
user’s perception towards the implementation of e-health systems. These sentiments were
echoed by a number of respondents in the following narrations:
“Senior managers pretend that they are demonstrating support for the new
system, but in fact they are not” (C10).
“Lack of support at various administrative levels adversely affects the
implementation of ehealth” (C11).
“There are many ways to make the e-health work, among those means
government support for the program at the national level” (C1).
“I cannot trust the management unless I see a radical change to help me to do
so” (C13).
“The existence of top management support is an important indicator for us to
trust the e-health systems” (C5).
“We did not take adequate encouragement from the senior management to
adopt and use new systems” (C3).

154
“Top management is hesitant to allocate resources for e-health implementation
as they do not buy in to the idea” (C14).
“Generally let me say that there is lack of good will among the top management
in supporting implementation of e-health systems”(C14).
“I believe organisational politics take the centre stage when it comes to
implementing e-health systems” (C8).
A number of the respondents were of the opinion that the presence of a national vision
regarding the implementation of technology would be a crucial tool that can support the
successful implementation of e-health systems in Kenya.
“I think there is a need for a common national vision between all health
institutions on the way forward towards e-health implementation” (C13).
“It is noted that different visions of health institutions affect the implementation
of e-health systems” (C22).
“I do not think that the government's vision is clear on the implementation of
information technology, especially in the healthcare sector” (C16).
“There is need to have a clear government vision on implementation of e-health
in the country” (C16).
155
Whereas others cited that there was lack of innovativeness orientation in the organisation
that cripples the implementation
“The management does not encourage innovativeness” (C6).
“Top management is not keen on new ideas and emerging fields. They are very
complacent towards innovation” (C11).
“Top managers do not reward creativity and innovation, this creates a
demotivated workforce not interested in exploring new systems. Essentially they
kill creativity” (C3).
Majority of the respondent’s agreed that there are inter departmental conflicts existing that
affect implementation of e-health systems. This is coupled with conflicts of interests among
the stakeholders, where by personal interest over ride the organisation’s interest;
“There is no goodwill among the stakeholders” (C1).
“Conflict among various stakeholders in the organisation is quite eminent thus
the message gets lost in between” (C12).
“Personal gains override the organisation gain” (C14).
“I do not disagree that there are very many interested parties along the chain
thus the message gets lost somewhere” (C1).
“There is simply too much organisational politics that suppresses progress of
implementation of e-health systems” (C6).
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Lack of key stakeholder’s involvement in the decision of design and implementation of the
systems was mentioned as an issue that affects its implementation.
“We are not aware about the existence of the systems” (C25).
“We were not consulted when decisions were being made on development of the
systems” (C2).
“None of us were incorporated in the system implementation team” (C7).
“The top management is reluctant to involve all the stakeholders in the e-health
project” (C18).
In addition sometimes clinicians act as consultants yet they are not technically qualified
system programmers due to lack of training in medical informatics that helps them
understand implementation.
“Have seen my colleagues acting as the lead consultants in the system
implementation yet they have no idea how systems are developed” (C28).
“At times my colleagues are called upon to lead the implementation team yet
have very little IT skills in general” (C4).
“Sometimes wrong people are put to spearhead the project which definitely
leads to high failure rate” (C16).
157
Unrealistic expectation of benefits on investment from the systems was highlighted. In this
regard meaning there is lack of clarity concerning specific cost benefits to all stakeholders,
thus management are lethargic about supporting the project which affects implementation of
e-health system.
“There is solid absence of economic impact of e-health to the organisation”
(C13).
“Coupled with lack of clarity regarding specific cost versus benefits to all
stakeholders” (C10).
“The perception IT is seen as a cost centre rather than a strategic enabler”
(C9).
“I think the management does not stand to benefit directly from investing in e-
health” (C23).
Majority cited bureaucratic procedures and structures existing in the organisation as a barrier
to e-health implementation. This is felt in the supply chain processes that leads to
unnecessary delays and ends up being expensive and time wasting;
“Red tape bureaucracy is the characteristic of most institutions; this however
leads to a lot of time wasting and energy” (C1).
“Its impossible to get things done quickly in organisation because of the
existing bureaucracy” (C2).
“Even small things have to be subjected to a lot of bureaucratic procedures
thus this can be a barrier to e-heath implementation” (C6).

158
“How will we get ever get rid of this bureaucracy in the institutions. It really
stifles progress” (C1).
Lack of IS leadership is lacking in the organisation as there are no champions for e-health
project in general leading to implementation.
“There is no one to champion the project in the organisation”(C7).
“Management is hesitant nominating a champion to spear head the e-heath
project” (C6).
“No one is courageous enough to champion the e-health project” (C4).
“Often the e-health project lacks leadership thus the message gets lost in
between” (C2).
Despite the existence of ICT policies in the organisation, more often than not the policies
exist but they are never followed. This directly affects implementation of e-health
“ICT Policies are made but not followed” (C12).
“Policies are there but there is no follow up to ensure they are implemented”
(C12).
“There is a clear disconnect between policy formulation and implementation as
the latter is not done” (C3).
“There is no monitoring and evaluation done to ensure the policies are
implemented” (C2).
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A few of the respondents stressed the importance of partnership with public private
partnership sector institutions, in the implementation e-health systems
“Without working hand in hand with the private sector, the public sector
cannot implement e-health alone” (C13).
“For example, the public sector needs to tap into private sector expertise in the
field of training of latest technologies” (C6).
“The public sector would benefit from the experience of the private sector in
implementation of information technology” (C2).
“As partners from the private sector, we face difficulty in dealing with some
public sector employees” (C21).
A number of other respondents said there was need to have a monitoring committee made up
of stakeholders with a range of experience from both the public and private sectors to
oversee the implementation of e-health systems. This would in the long run promote trust
between the two sectors and create a positive effect on the implementation of e-health
systems.
“I suggest there should be a committee for managing the e-health project that
must be completely independent and has its own budget otherwise things will
remain the same” (C2).
“There are several difficulties, including lack of an advisory committee to
follow up the implementation of e-health systems” (C6).
160
There is lack of proper trust and cooperation between public and private institutions to set up
systems that can share data. Trust issues among the various stakeholders were cited as a
barrier to implementation as many organisations had their own reservations on sharing of
data among each other.
“The public and private institutions do not trust each other enough in order to
share data” (C10).
“Organisations need to work towards being trusted if they were to share data
among each other” (C2).
“Will the data be used to source for more funding?” (C2).
“We are not sure for what purpose our data will be used for in case we agreed
to share” (C7).
“Organisations need come up with policies that protect the sharing of the data
among various entities” (C28).
“There is lack of goodwill among the healthcare players to set up mechanism to
share data” (C1).
“We cannot trust our partners in this aspect of interoperability” (C24).
“Who is likely to benefit from sharing of the data” (C14).
“Do we have measures in place that support interoperability” (C2).
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Others cited the conflict of interest in the health insurance plan among the various
stakeholders. This is because of the conflict of interest among the parties thus they may not
agree to have one comprehensive plan that can cater for the costs of all the patients no
matter which facility they are being attended to equitably which in turn affects e-health
implementation;
“We are opposed to the proposed health insurance plan” (C13).
“The proposed health insurance plan does not meet our interests” (C24).
“Is the government willing to sustain a healthcare sector plan for all citizens”
(C13).
“The capitations are too low for our facility thus does not meet our institution
needs” (C6).
Additionally some pointed out on the need for the Government of Kenya and more so the
Ministry of Health to try and gain some experience from other countries where e-health had
been a success. Netherlands and Finland for example, can be considered a model that can be
used to benchmark against;
“I believe that there is a need for the government to review such e-health
projects in countries that have successfully rolled it out” (C13).
“Why can’t the government borrow aspects of success from the developed
countries” (C22).
“I think the main question we ask here are our stakeholders willing to borrow a
leaf from developed countries or we are locked up in negativity”(C22).

162
“Why doesn’t the government stand to benefit from the experiences of countries
that have advanced in the ranks of the world rankings in areas of e-health
implementation?” (C4).
Consequently it was observed that there was a consensus on the significance of effective
organisational efficiency concerning e-health implementation. Largely majority of the
respondents expressed their concern that organisational efficiency positively affects the key
processes that support the implementation of e-health frameworks. Thus the researcher
noticed that the absence of an effective organisational efficiency is among the significant
factors that may hinder the implementation of e-health systems in Kenya.
4.12 Legal Environment
Various ideas related with the legal setting were recognized from the reactions of the
respondents. These included: lack of legal environment for e-health transactions, absence of
e-laws for online patients data transactions, out-dated set of legislations, lack of patient data
protection laws, lack of enforcement of the existing law. These ideas are portrayed in Figure
4.12.
163
Weak laws Low good will in
support of laws
Legal
environment
Implementa Actual
E-laws lacking
Legal tion of e- use of
environment health the

Out-dated
legislations Influences systems Influences systems
Data protection
laws
Enforcement
issues
Lack of awareness
and importance of
laws
Figure 4.12: Legal Environment Category has an influence on the Implementation of

e-health Systems
A number of concepts were acknowledged mirroring on the qualities of the legal setting as
important in implementation of e-health frameworks. The reactions originated from those
met mirroring the level of mindfulness about the significance of legal setting characterised
by the need of having efficient and effective laws that to ensure protection of patient’s data
online. For instance, some respondents pointed out that the current laws and regulations that
guard patient data are obsolete, and don't keep pace with current patterns. The revising of
such laws particularly those identified with e-health will positively affect its
implementation.
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These sentiments were echoed by a number of respondents in the following narrations:
“The laws and regulations existing are out dated so they should be revised to
cover all e-health transactions” (C12).
“The existence of laws, increases users trust in the use of IT, particularly e-
Some respondents felt that the laws are lacking to protect patients data online which affect
implementation
“There are no laws that protect confidentiality of patient’s data online” (C1).
“No law exists that guides on ethical issues of patients data online” (C4).
“The laws existing do not address medical record portability for instance”
(C25).
“We are concerned about the security of our patients data over the network as
there no laws in place to protect it” (C1).
Whereas others were of the opinion that there are no laws and penalties existing to guide or
compel all health institutions in sharing of patient’s data thus it will be difficult to achieve
interoperability of the systems
“there is no law that exists to compel all healthcare institutions to share data”
(C20).
“Private hospitals are unwilling to share data with other institutions” (C20).
“The donor funded system projects are unwilling to share their data with other
institutions as there is no law that exists to compel to do so” (C4).
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“Institution hoard their information as no regulation exists compelling them to
share” (C4).
A few indicated that even where the law exists but it is not enforced and often ignored
which affects interoperability of systems thus it is difficult to know what is exactly
happening in the healthcare sector;
“There are laws entrenched in the constitution like the public health act which
compels all health facilities to report their data, even then some facilities do not
report the data to the relevant authority” (C11).
“There are no penalties set for those who do not report their data to the
relevant authority” (C11).
“There is no proper follow up or penalties stipulated in the law for those that
do not report the data” (C2).
In addition others felt that there are no laws that exist compelling the private hospitals to
report their workload on the District Health Information System (DHIS). Therefore the
District Health Information System (DHIS) only contains workload from public healthcare
sector.
“Currently DHIS does not capture data from private hospitals” (C5).
“This may lead to under reporting and poor interventions” (C9).
“This may affect planning and policy formulation” (C4).
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Many were of the opinion that there was the crucial issue of having efficiency in the legal
environment. This calls for the need to have full commitment in the implementation and
enforcement of laws and regulations to protect patient data online. Thus this would boost the
users trust in the utilisation of the system and implementation.
“There is insufficient legal framework in place to protect e-health users” (C5).
“I wouldn’t expect the any institution to support me legally in the case of a
serious online security breach” (C2).
“The absence of laws, decreases users trust in the use of e-health systems” (C7).
Others were of the opinion that there was the crucial issue of having effectiveness in the
legal environment. This calls for the need to have full commitment in the
implementation and enforcement of laws and regulations to protect patient data online.
Thus this would boost the users trust in the utilisation of the system and implementation.
“We are concerned that these laws reduce the potential risks and ensure the
protection of the patient’s data online” (C12).
“The absence of laws, decreases users trust in the use of e-health systems”
(C14).
Thus it was observed that there was an agreement on the significance of an effective legal
environment in the successful implementation of e-health implementation. By and large
many of the respondents were of the consensus that effective laws regarding e-health
systems would have an effect on the implementation of e-health systems. Accordingly the
researcher noticed that the presence of an efficient and effective legal environment is among
the significant factors that may hinder the implementation of e-health systems in Kenya.
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4.13 Socioeconomic Environment
A number of concepts associated to the socioeconomic environment were recognized from
the reactions of the respondents. These include: purchasing power, population growth,
digital divide, distribution of resources, generation gap, poverty levels, literacy,
demographic characteristics, low income rate, sustainability, ROI, Equity and access. These
Low income rate

ROI
High poverty
levels
Demographic
characteristics
Purchasing power
Actual
Population
growth
Social Implementati use of
Digital divide economic Influences

on of e- Influences the
environment health systems
Unequal distribution systems

of resources
Generation gap
Poverty levels
Equity and
Literacy access
levels
Figure 4.13: Social Economic Environment Category has an influence on the

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The concepts that were acknowledged mirrored socioeconomic aspects that would affect the
implementation of e-health frameworks. The reactions originated from those met mirroring
the level of mindfulness about the significance of socioeconomic forces in affecting user
attitudes regarding implementation of e-health systems. The concepts, namely purchasing
power, population growth, digital divide, distribution of resources, generation gap, poverty
levels, literacy, demographic characteristics, low income rate, sustainability, ROI, Equity
and access have an effect towards implementation of e-health systems.
Some respondents pointed to elements of instability (e.g. prices of computers and
accessories, connectivity) in the local markets as potential threat to the IT platform thus
influencing the economic power of the users. Most of the users may not be economically
empowered to afford the electronic gadgets to use. These sentiments were echoed by a
number of respondents in the following narrations:
“I am not able to afford monthly subscription for Internet services” (C16).
“I am not able to afford the prices of computers and accessories” (C16).
“Most of us cannot afford to use the m-health as it is very costly” (C5).
In the same context there are high levels of poverty levels coupled with low income rate.
Majority of Kenyans live below a dollar a day. Much of what is generated goes to food
clothing and shelter thus pushing them to e-health would not be affordable. This is regarded
as a luxury and a preserve for the rich persons. Thus they would rather stick to the
traditional healthcare methods that they are used to rather than use technology.
“We hardly make too much than the need for basic needs” (C21).
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“E-health may be regarded as a luxury not a basic need” (C21).
“The current healthcare is meeting my needs so I do not see why use
technology” (C11).
“I believe most citizens would not be convinced to incur extra cost on internet
bundles because of the prevailing economic situation” (C18).
“Are we going to buy food or is it bundles now” (C18).
A number of the respondents cited barriers such as poor electricity availability and
connectivity issues especially in the rural areas which affects access to the e-health
applications
“Most of the rural areas are not connected to electricity so using electronic
gadgets might be difficult” (C9).
“I agree the rural areas are worst hit when it comes to connectivity issues”
(C9).
“Internet connection is stronger in urban areas than rural areas” (C1).
“Sometimes we have to take the phones to the nearest market for charging as
electricity is not available in the households”(C7).
In addition there is the issue of digital divide especially among the rural and urban
population. This refers to people who have the skills to use the technology and those without
the skills. Thus m-health which is an application of e-health may not be successful. A
sizeable number of people in the rural areas have no competency on how to navigate the e-
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health systems. There is an element of high IT illiteracy among the rural population. Thus
this would hinder them from utilising the technology properly.
“There are many people who have no idea how to operate electronic gadgets in
the rural areas yet m-health would be transmitted through this platform” (C6).
“They use mobile phones for calling and texting only how then would they use m-
health which is part of e-health” (C6).
“I believe the rural folk have little idea on how they can access healthcare
through their mobiles. They may be lacking the knowledge or are ignorant”
(C28).
“I think people in the rural areas need to be trained on what e-health is and
how they can use various devices to benefit from the technology” (C29).
“Majority of the people if the rural areas do not know how to manipulate
information systems” (C2).
“Most of the rural residents have other pressing problems than just thinking
about accessing healthcare on the phone” (C3).
Whereas others were keen to highlight the importance of demographic factors such as age,
literacy levels in influencing attitudes towards the implementation of e-health systems. This
is more prevalent in the rural areas where literacy levels are extremely low as compared to
the urban folk.
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“Younger people would be more likely to adopt the technology than the
elderly” (C13).
"We expect people who live in urban areas to be more likely to utilise e-health
than those in rural areas” (C13).
"People with higher education would be more likely to utilise technology” (C2).
“People with less education are less likely to utilise technology” (C2).
“Illiteracy coupled with advanced age is a big problem in the society, so when
it comes to introduction of technology resistance could be high” (C2).
A few of the respondents alluded to the fact that there is unequal distribution of resources
especially between the rural and the urban population. The urban folk are more advantaged
when it comes to interaction with the recent technology unlike the rural folk who most of the
times get absolute devices.
“There is a tendency to lack electronic devices in the rural areas” (C21).
“We do not have access to the recent technologies” (C21).
“Technological resources are more concentrated in the urban areas than the
rural areas thus the urban institutions are at a better advantage” (C18).
“Even where there are available there are beyond the costs of most of us” (C2).
“Sometimes what we have at our disposal is obsolete technology that may not
be compatible with e-health systems” (C24).
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Accordingly there was consensus of the significance of social economic elements in the
implementation of e-health frameworks. The respondents acknowledged that the presence of
effective social economic elements positively affects the implementation of e-health
frameworks. The researcher noticed that guaranteeing the improvement of the social
economic factors is among the significant elements for the implementation of e-health
frameworks. As a result the researcher noticed that the absence of effective social economic
factors was among the significant factors that may hinder the implementation of e-health
systems in Kenya.
4.14 ICT Competence Environment
A number of concepts associated with ICT competence were recognized from the responses,
namely; shortage of clinicians, lack of qualified technical team, shortage of skills in health
informatics among health professionals, lack of ICT in health professional curriculum, high
turnover of ICT personnel, technically inadequate expertise. These concepts are described in
Figure 4.14.
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Lack of training Inadequate
programs resources for
training
Shortage of
clinicians
Qualified
technical team
lacking
Shortage of
computer skills in Implementa Actual
health informatics
ICT tion of e- use of
Influences Influences
competence health the

Lack of IT in Health
professional
curricula systems systems
High ICT
personnel turnover
Inadequate Basic IT Skills

expertise lacking
Figure 4.1: ICT Competence Environment Category has an influence on the

Generally the concepts that were acknowledged revealed the description of the ICT
competence that is necessary to support implementation of e-health systems. The reactions
came from those interviewed showing the level of responsiveness about the significance of
ICT competence in support and maintenance of the systems. For example, some respondents
pointed out that the there was a shortage of healthcare workers in general. This made it
difficult for them to create time to learn new technology. Majority considered the
technology as an intrusion in their busy working life.
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These sentiments were echoed by a number of respondents in the following narrations:
“We are suffering from chronic shortage of health workers” (C15).
“The clinicians are few and the patients are increasing each day therefore we
concentrate on the core business which is treatment of patients not learning
how to use technology” (C23).
“The number of patient keeps on growing so we don’t have time to accept
gadgets that might interrupt our work” (C21).
“We do not have enough time to learn new technologies” (C23).
In the same context there is lack of skills in health informatics among health professional
coupled with lack of ICT in health professional curriculum. This poses a challenge in
implementation of e-health as most healthcare workers have no skills on how to use the
system;
“We have no skills in health informatics” (C13).
“We are trained to treat and not use electronic devices” (C17).
“I have no idea how I would mine data from the system” (C20).
“I accept iam not sensitised on how to use e-health systems” (C19).
“This was not part of our curricula in medical school” (C22).
Moreover there is high ICT personnel turnover in the organisation. The ICT personnel
are on always on the look out for greener pastures hence when this happens the
institution is usually left with no option than to hire others. The process of recruitment is
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both expensive and time consuming. Thus this may affect the implementation of e-health
systems;
“We are constantly having the IT officers leaving the institution” (C1).
“We work as a team and cannot perform without the assistance of IT officers”
(C11).
“The turnover rate of our IT is alarming” (C4).
“I see new faces of IT officers each month” (C8).
“Believe you me that we have highly qualified IT officers in the country but the
facility cannot afford to pay them” (C20).
“The IT officers are on high demand out there so containing them here is
difficult” (C14).
In the same context the organisation relies on inadequate expertise which leads to poor
system analysis. When this happens the user requirements are not met which might lead to
sabotage and resistance on the part of users. This then affects implementation of the e-health
systems.
“We rely on technically inadequate expertise for advise” (C3).
“In most cases the project is headed by staff who are politically correct to the
management but not technically correct thus the projects failure rate is so
high”(C8).
“I agree the team spearheading the implementation are not technically
qualified” (C9).
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“The confusion lies on who is technically qualified to head implementation”
(C14).
“Organisational politics plays a key role in assigning technically inadequate
staff to spearhead the project. As a result the project is bound to fail” (C6).
Lack of a qualified team to provide support and assistance in the implementation was cited.
In this regard the organisation may attribute this to cost of hiring the skilled IT officers and
is forced to rely on interns;
“We do not have qualified technical team to support the process” (C27).
“We rely on interns for provision of IT service and as such not qualified to
support the implementation” (C5).
“There are very few qualified IT officers in the organisation thus IT support is
a real problem” (C16).
“Its costly to hire qualified IT officers” (C29).
“The organisation finds it hard to remunerate the IT officers well thus there is a
high turnover for greener pastures” (C26).
Accordingly it was clear that there was an agreement on the significance of ICT competence
in the implementation of e-health systems. The respondents were of the opinion that the
presence of an efficient ICT competence had a positive effect on the implementation of e-
health systems. Thus the researcher noted that ensuring the availability of an effective ICT
competence is among the success elements required for the implementation of e-health
systems.
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4.15 E-Standards Environment
A number of concepts linked with e-standards were identified from the responses, lack of
available standards, no legislation exists, standards do not address one unified area of
technology, conflicting and overlapping standards, limited participation in standards, lack of
importance of standards. These concepts are described in Figure 4.15.
user friendly
Lack of standards
importance of
standards
Too many
standards
Lack of
uniformity in
standards
Actual
Overlapping
standards Implementatio use of
E-standards Influences n of e-health Influences

the
Inadequate environment system

standards systems
Lack of
enforcement of
standards
Lack of e-health
standards
Limited participation
in standards
development
Figure 4.15: E-standards Environment Category has an influence on the

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Certainly the concepts that were recognized demonstrated the importance of e-standards that
are necessary to support implementation of e-health systems. The reactions came from those
interviewed showing the level of responsiveness about the significance of e-standards in
implementation of the e-health systems. For example, some interviewees pointed out that
there was lack of e-standards to share data. These sentiments were echoed by a number of
respondents in the following narrations:
“There are no available standard on how the public and private health care
sector can share data” (C7).
“No standards exist on how healthcare facilities can share data across the
platform” (C2).
In the same context there was lack of standardization and certification of e-health resulting
in lack of system and data interoperability
“The healthcare facilities do not share data as there is no agreed standard for
interoperability” (C17).
“Interoperability is difficult to achieve because of lack of standards” (C2).
“How then do we achieve system integration without an existence of relevant
standards” (C22).
A contributing factor to the lack of standard is the lack of incentive for data sharing among
the healthcare institutions.
“There are no incentives offered for data exchange” (C10).
“We are unwilling to share the data” (C17).

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“Incentives are lacking for data sharing” (C28).
A number of the respondents purported that the available standards do not focus on one
unified area of technology. Thus there are many overlapping and conflicting standards
“What we have in general is many standards that do not address one area of
technology application” (C19).
“There are many existing some conflicting and overlapping as well” (C10).
“There are too many available standards so which is which” (C27).
The only available standard is the one that supports District Health Information Systems
(DHIS) and Electronic Medical Record (EMR), however this has limitations as private
hospitals do not report their workload to the system. It only caters for the public healthcare
facilities
“The private healthcare sector is not compelled to report their workload thus
this standard is not all inclusive of all health facilities” (C2).
“Why then do private hospitals fail to upload their data on the system” (C16).
“The DHIS standard is not all inclusive thus we need one that addresses all
aspects of patient’s management” (C22).
“The only standard am aware of is the EMR standard of 2010, however this
particular one does not address medical record portability as well as ethical
issues of the patient information”(C28).
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Whereas, others mentioned lack of implementation guidelines for the accessible standards as
barrier to the implementation.
“The available standards do not have implementation guidelines” (C3).
“The standards lack foundational infrastructure” (C25).
“We no idea on how to implement the standards” (C25).
Besides the stakeholders do not appreciate the importance of having standards at
institutional level thus no or little resources are allocated to the process.
“The management is not committed to development of standards” (C12).
“There is absence of importance of standards among the stakeholders therefore
little effort is made to allocate resources that support the process” (C14).
“Little resources are allocated for development of the standards” (C18).
Majority were of the opinion that low level of representation of African countries in
standard development, meant that the continent’s ability to influence development was
minimal. Thus this resulted to standards that do not address the peculiar local needs.
“We are not involved or consulted when these standards are being developed”
(C11).
“Little effort is made to involve us in the development of the standards” (C15).
“Our views are not sought during the development of the standards” (C8).
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“There is very low representation of African countries in the development of
standards” (C8).
“Most of the standards tend to be western biased thus not helpful for our local
needs” (C8).
Similarly in the same argument others said the available standards are not user friendly
“The available standards are difficult to understand and apply” (C10).
“The standards are not easy to use either” (C24).
Finally others suggested the need of adopting a user centred standard of general usability
principles. This ensures uniformity in the use of terms and definitions, simplicity and
comprehension by non technical users of the standards.
“There is need of adopting a user centred application to standard development”
(C3).
“For consistency and simplicity there is need to have a user centred standard of
general usability principles” (C27).
Consequently it was apparent that there was agreement on the significance of e-standards in
the implementation of e-health systems. Generally the respondents agreed that the presence
of detailed user centred e-standards had a positive effect on the implementation of e-health
systems. Thus the researcher noted that ensuring the availability of user centred e-standards
is among the success factors necessary for the implementation of e-health systems.
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4.16 Chapter Summary
This chapter presents the findings of data analysis of this study through the application of
grounded theory methodology. This is the process where categories and concepts are linked
systematically through constant comparative analysis between the codes. Examples of the
reactions from the respondents were provided to show the support of the emergence of
categories. The main purpose of this chapter was to investigate elements that affect the
implementation of e-health systems in the healthcare sector in developing countries with a
focus of the Kenyan sector utilizing a data driven approach. The study began by collecting
data using interviews. The interviews were then transcribed. This was then followed by
coding of the data through open, axial and selective coding. The study generated thirteen
categories that gave an indication of the issues that affect the implementation of e-health
systems in Kenya.
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CHAPTER FIVE
DISCUSSIONS
5.1 Introduction
This chapter provides discussions on the issues that were analysed in the previous chapter.
The final framework developed explains the issues that need to be addressed for successful
implementation of e-health in the healthcare sector to take place today in developing
countries and specifically Kenya.
5.2 Factors that affect the Successful Implementation of e-health Systems
The analysis of the data generated 13 key elements recognized as follows: quality of e-
health systems, benefits of e-health systems, macro political environment, sociocultural
environment, online safety and security, e-standards, technological environment, change
process management, systems integration, ICT competence, organisational efficiency ,
socioeconomic environment and legal environment that were later refined into five
categories namely political e-readiness, managerial practices, IS Capability, societal e-
readiness and regulatory framework. The following section describes the detailed
discussions for each of the 13 factors generated in chapter four.
5.2.1 Quality of e-health System as a Determinant for the Success of e-health
From the preceding studies, quality of e-health systems was regarded as a contributing factor
to the success of IS implementation including e-health systems (Jennett et al., 2004;
Eysenbach et al., 2007; Korpela, 2011). The results of this study showed that perceived
quality of e-health systems is probably to be amongst the significant factors of successful
implementation of e-health systems. In essence quality of systems can be measured by the
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following: greatly responsive to users needs, enabling users to recall patients medical history
without difficulty, having e-health systems available throughout the day and enabling
better interaction with the all the stakeholders, responsiveness, context -focused, well-
defined, interoperable, online support, user friendly, reliable, security, well-structured, and
interactivity. Furthermore for e-health system to add value along the implementation chain
the systems need to meet the above minimum qualities. This will make users either to reject
or accept usage of the systems all together which translates to successful or failure of the
implementation of the systems. Moreover users are likely to accept systems that they
perceive that they are user friendly and reliable in carrying out various processes.
5.2.2 Sociocultural Environment as a Determinant for the Success e- health
The preceding studies indicate, sociocultural environment is considered a key contributing
factor for the success of IS implementation including e-health systems (Treurnicht, 2009;
Oladosu, 2009b; Bhatia, 2014). The results of this study pointed towards the development
of sociocultural environment as being probably among the key elements of successful
implementation of e-health systems. Generally users’ perceptions on technology can affect
how a new technology is conceptualized and if it will be accepted and further utilized.
Reference is made to a study that involved exploring hopes and fears in the implementation
of electronic medical records in Bangladesh (Hedstrom & Andersson, 2012), it was found
that most users are scared of utilizing ICT in health care sector based on their perceptions
about it. In this study for example, some stakeholders thought that utilizing technology in
their practice would be more time consuming, and an interruption to the patient’s privacy.
Whereas others felt that it would negatively influence the time they could spend with
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patients as well as depersonalize healthcare. Additionally more explicitly interfere with
their rapport with their patients. Furthermore some of the respondents consider e-health
systems as a threat to patient privacy and confidentiality and as a potential tool for ‘Big
Brother’ interference in their practice. Thus this indicates that for successful implementation
of e-Health to be done stakeholders must change their attitudes towards e-Health.
Moreover cultural issues need to be sorted out as well in view of appropriateness and
relevant content (Bhatia, 2014). A further element of culture is the necessity to examine and
challenge the cultural inhibitions and barriers within society and institutions that hinder
effective utilization of e-health systems. Accordingly the management of the organisation
can encourage users to accept technology by building their confidence levels through
introduction of e-health education programs. In the same context seminars and workshops
can be held to sensitize users about the benefits of e-health in their daily practise. Similarly
early participation of users puts them at the leading end, instead of just forcing them to
accept an already developed system and forcing it on them. Moreover change process
management with users, as well as staff should be encouraged at all levels. Besides a local
champion may be appointed, who can be sensitized in depth about the system and may serve
as the connection between developers and staff. This would go along way in solving the
problem of user resistance to technology (Akanbi et Al., 2011).
Furthermore Oladosu, (2009b) suggests sensitization programs and workshops focusing on
the current ICT trends and alignment to business process would need to be arranged. The
management may also conduct short courses on ICT skills courses for the staff on a regular
basis. Besides introduction of bonuses and reward system can also entice the users to
embrace technology. Furthermore stakeholder’s involvement in the implementation process

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may encourage participation and reduce sabotage. In conclusion to resolve this, differences
between existing organizational culture and changes need to be carefully discussed by
evaluating the possible benefits and challenges when introducing e-health systems.
5.2.3 Online Safety and Security as a Determinant for the Success of e-health
Initial preceding studies, indicates online safety and security as a consideration for the
success of IS implementation including e-health systems ((Mugo, 2014; Xiangzhu et al.,
2013; Oladosu, 2009; Ronen et al., 2011). The results of this study highlight the issue of
maintaining the safety and security of e-health systems as being among the elements of
successful implementation of e-health systems. Normally privacy and security of electronic
patient’s data are of pertinent significance if e-Health is to increase confidence amongst
healthcare stakeholders. Privacy is the claim of individuals to determine for themselves
when, how, and to what extent information about them is communicated to others.
On the other hand security can be referred to as the degree to which private information can
be preserved and transmitted such that access to the information is limited to authorized
parties (WHO, 2013). Largely ICTs are susceptible to security and privacy breaches which
negatively impact their implementation in the healthcare sector (Xiangzhu et al., 2013).
Fundamentally organizations should seek to introduce digital signatures to increase the
security concerns of all the users of e-health. Privacy and protection of the information
should be guaranteed by adopting advanced security techniques. In addition system
authorization, authentication and controls should be introduced at all levels of use. Similarly
security sensitization training should be carried on a regular basis. Moreover the
management should support the process by ensuring tight security measures are put in place
and allocate resources for supporting the security procedures. Equally new innovations such
as block chain technology can be embraced to protect the patient’s data on the network.
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Certainly the block chain technology can have a great impact on securing patients data
online. A patient’s differing interactions in the healthcare system can not only be repaired,
but having multiple checkpoints rather than one single gateway for sensitive data can also
improve security. Block chain relies on established cryptographic techniques to allow each
participant in a network to interact without preexisting trust between the parties. Patients
who are part of the block chain would then be able to approve or deny any sharing or
changes to their data, helping to ensure a higher level of privacy and greater consumer
control. Whereas this is similar to how health information exchange may operate there is an
important difference. The validation aspect is what will set block chain technology apart.
Therefore patient records or data on a block chain are secure, almost impossible to
manipulate, auditable and easily accessible with public and private keys. In essence security
is totally guaranteed.
5.2.4 Technological Environment as a Determinant for the Success of e-health
The technology environment incorporates the internal and external advances that are
significant to the implementation of e-health frameworks. In light of past reviews, the
technological platform is regarded as a contributing factor for the achievement of IS
implementation including e- health frameworks (Mbarika, 2004; Anwar, 2012; Qureshi et
al., 2013; Mbarika et al., 2012; Korpela 2013; ITU, 2015). The findings of this review
demonstrate that the technological components are probably among the key elements of
successful implementation of e- health frameworks. Korpela, (2013) notes that internet
availability is essential for effective implementation of e-Health frameworks. This study
revealed that occasionally some stakeholders may be eager to conduct e-health searches
online in order to share health information with their colleagues in others parts of the world.
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However lack of ICT infrastructure restrains them from carrying out the queries.
Furthermore combined with the low rate of internet browsing and low transfer speed are
among a number of the difficulties confronting e-Health implementation in developing
nations. Generally with connectivity you have to deal with things like the lack of an
enabling telecommunication policy and regulatory environment; access to electricity, solar
power options, back-ups, insufficient infrastructure, connectivity access and high costs. The
finer these things are working the more prominent the possibility for effective
implementation of the systems.
Omary et al (2009) indicates that due to inadequate ICT platform and internet infiltration in
Tanzania, the majority of regions in the country cannot support internet deployment, which
in turn, hampers e-Health implementation. Moreover, even in developing nations that have
high internet infiltration, bandwidth speed may in any case be a challenge, while creating a
barrier to implementation of e-Health frameworks. Nevertheless organizations need to
embrace selection of appropriate technologies and solutions to be used within their specific
environments, bearing in mind the current state of power supply standards and
telecommunications infrastructure. Mainly healthcare needs should drive acquisition of
technology and usage and not the other way round (Anwar, 2012). By and large other focus
should be on establishing internet connections for health institutions; establishing websites
for each health facility; building local area networks and establishing telemedicine facilities.
In this case the adoption of open ICT platform technologies should be encouraged, and
maintenance of adopted technologies should be done.
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In addition to solve the interoperability and maintenance problems, simple, local, user-
friendly software should be used. Moreover developing countries may opt for open source
software due to its open methodology and lower expenses. Besides, they could build on
current already existing and working innovations, while customising their own relevant
solutions. Thus the macro political environment may play a key role in regulating computer
prices, systems prices, and internet access costs, such that more people can have access to
such resources. Similarly systems standards and guidelines need to be in place and assessed
for suitability prior to extensive implementations (WHO, 2012).
5.2.5 Macro Political Environment as a Determinant for the Success e-health
Past studies indicate that macro political environment is observed as a determining factor
for the achievement of IS implementation including e-health frameworks (Oladosu, 2009;
Murray, 2010: Mbarika, 2013). The aspects of micro political environment that emerged
include poor history of IT implementation in the healthcare sector, social and economic
development, foreign donor investments, poor collaboration with both private and public
sector, insufficient funding, conflicts of interest, low political goodwill in sector, inadequate
knowledge about e-health frameworks in the region, embedded corruption, ROI is lower in
healthcare than other sectors therefore entrepreneurs are reluctant to invest in the sector. In
this study macro political environment is referred to as the external environment that is
impossible to control and generally has an effect on the aspect of decision-making in the
country. This is predominantly on national strategies and policies, which implies the effect
on services and functions provided by various organisations.
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The micro political environment is mandated to ensure there is equitable distribution of
resources equitably to the entire population. This may address the issue of inadequate ICT
resource distribution among various healthcare institutions. Indeed the outcomes from this
study demonstrate that the improvement of a conducive political setting is probably among
the key determinants of effective implementation of e-health systems. The study revealed
that there is very little or slow yields on e-health systems in developing countries. Thus
these systems do not yet show up on the thrust areas of entrepreneurs in developing
countries to invest in the sector (Murray, 2010). As a result this discourages the potential
entrepreneurs in investing in e-health systems.
Moreover politicians are not very keen on focusing on the healthcare sector IT investment as
the return on investment is very low coupled with deep conflicts of interests among the
political class. By and large the political environment is characterised by personal interests
that over ride the over role interests of the society. Thus the politicians may be reluctant to
support the implementation of e-health systems because they do not see the benefits in the
short run. Accordingly the political environment should establish an enabling policy
environment that will encourage the private sector to seek funds for capital investments that
will allow the introduction of new cost-effective technologies. Additionally the political
sector needs to make policies that attract investments in ICT infrastructure and services in
the health sector, using domestic and external financing.
Likewise there is need to ensure there is integration of e-health in all budgetary processes to
promote sustainability of the e-health projects. Equally they should develop policies on e-
Health which articulate the commitment of the government to invest in an ICT-based
healthcare system. Furthermore international partners and donors should be encouraged to
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support national efforts towards implementation of e-health projects. Similarly there is need
to come up with a social national health policy plan for all citizens that can work for both
private and public facilities. The current NHIF cover capitations are too low to match the
needs of the private sector that does not get government subsidy to run their facilities. In
addition the political sector should seek to equitably share the resources to the population to
reduce the digital divide among the rural and urban population. Moreover Public Private
Partnerships (PPP) should be encouraged so that the various institutions may be able to
share resources and expertise. This would help fast-track e-health implementation especially
in the public health sector which still lags behind in innovations utilization.
5.2.6 Change Process Management as a Determinant for the Success of e-health
The preceding studies have highlighted change process management as a contributing factor
for the success of IS implementation including e-health systems (Fanta, 2015; Anwar, 2012;
Ekeland, 2010; Eysenbach, 2001; WHO, 2011). The analysis of this study indicates that the
change process management is probably amongst one of the key elements of successful of e-
health frameworks. Change process management is crucial in influencing the user’s attitudes
and commitment towards usage of e-health systems which translate to easier
implementation. Stakeholders need to be involved in the entire process of system
development from analysis to implementation stage. Thus by engaging stakeholders through
each stage of the e-health project reduces the likelihood of sabotage and resistance to the
innovation which negatively affects the implementation. The change process management is
necessary in promoting IS leadership in the organisation as well in identifying a champion to
advocate for the change. Such actions would ensure there is continuity plans put in place of
the initiated e-health projects. Likewise the change process management is important in
sensitizing the benefits of the systems to the top management which translates in resources
allocation to support the process.

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Fundamentally the management should demonstrate support commitment for change by
sensitizing employees to accept change through training or seminars. Furthermore they
should spearhead the process by nominating a champion to implement change as well as
engage all stakeholders in the change process. Equally the organisation needs to set aside
resources for supporting the change process. This will ensure there will be continuity plans
put in place for the smooth running of the project.
5.2.7 Systems Integration as a Determinant for the Success of e-health
System integration was regarded as a contributing factor for the success of IS
implementation including e-health systems (Iacovou, 1995; ITU, 2015; Siedlecki, 2001;
Kimaro, 2007). The findings of this study demonstrate that sustaining the integration
between various e-health applications was amongst the elements for successful
implementation of e-health system. Interoperability is referred to as the capability of two or
more systems or their components to share information and to utilize the information that
has been shared. In the health care context, whether regional, national, or global,
interoperability is commonly referred to as the capability of e-health systems to work jointly
within and across organizational boundaries in order to advance the effective delivery of
health care for individuals and societies. Interoperability is a fundamental component of
enabling desired cross-institutional point of care access to accurate patient data and to
achieve better health care outcomes, cost savings, and efficiencies (Korpela, 2013).
Mugo et al. (2014) suggests that in order to attain interoperability across institutions requires
coordination and cooperation among main stakeholders in the healthcare sector.
Consequently the government should ensure there is proper coordination between national
and county hospitals on issues of incompatibility and interoperability, reengineering of
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internal processes and synchronisation to exchange data. Ideally the donors should be
encouraged to have good will and allow integration of the donor funded systems and local
systems. In addition policies and laws need to be put in place to support the integration of
the systems and sharing of information. Furthermore various institutions can embrace some
of the new emerging technologies to increase the interoperability of such systems. For
example the block chain technology has the likelihood to address the interoperability issues
currently present in e- health systems and to be the technical standard that enables
individuals, health care providers, health care entities and medical researchers to securely
share electronic health data. A national e- health infrastructure based on block chain has far-
reaching potential to promote the development of precision medicine, advance medical
research and encourage patients to be more accountable for their health.
5.2.8 Organisational Efficiency as a Determinant for the Success of e-health
The findings of this study show that organization efficiency is among the determinants for
fruitful implementation of e-health frameworks. In light of past reviews, organizational
efficiency is observed to be a key determinant in the implementation of IS systems including
e-health systems (Avgerou, 2008; WHO, 2013; Qureshi et al., 2014; Ronen et al., 2011;
Juma et al., 2012). Senior management support refers to the extent of commitment and
resource support given by the top management for implementing of the systems. The
organisations are characterised by various issues that derail implementation of the e-health
systems. This include lack of top management support, accountability, innovativeness, IS
leadership, strategic orientation, trust issues, red tape bureaucracy, unrealistic expectations,
complacency, personal interests and conflicts of interests. The bureaucratic procedures in
the supply change processes hinders faster and easier decision making thereby crippling
implementation of the e-health systems. Thus the government can introduce laws that break
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some of these bureaucratic processes. In addition the organization may form a multi sectoral
and multidisciplinary consultative process involving all key stakeholders. This would
include the users and beneficiaries. This kind of a team should be used to fast track the
implementation process as well as ensure the change process management is done properly.
Moreover there is need to set up a monitoring and evaluation of systems to measure progress
in the implementation of e-Health project (Eysenbach et al., 2007).
Furthermore the top leadership should spearhead the project by supporting it by word and
action. In the same context the organisation needs to prioritise and set aside resources for e-
health project from capacity building to implementation details. The capacity building will
go along way in fostering innovativeness in the organisation as well as increase
accountability among the various stakeholders. The issue of trust among various health
institutions needs to be addressed so that interoperability of the systems is possible.
Fundamentally interoperability helps in sharing of patients data among various healthcare
institutions. Similarly streamlining of internal processes needs to be properly done so that
bureaucratic procedures are reduced as this acts as a barrier to the project as well as inviting
aspects of corruption in the process (Korpela, 2013).
Consequently there is need for a shared mind set between Information System managers and
organisation leaders to embrace new tactics in reaction to changes in the competition and
technology landscape in the system implementation (Ronen et al., 2011). The study also
found out that there was a lot of conflict of interest among the stakeholders where by the
personal gain override the organization gain, thus this creates a barrier towards
implementation of the systems. This conflict of interests may also be referred to as
organizational politics overriding the project. Many of the stakeholders seek to satisfy their
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personal interest as opposed to looking at the bigger good of the organization. Thus they
seek to benefit from the e-health project at a personal point instead at the expense of the
organization. Such behavior may cripple the process of implementation of e-health project.
This may be handled through change process management and having a good will for the e-
health project amongst other existing projects. Largely there is need for a change of mindset
on prioritizing e-health projects among other projects so that resources are set aside for its
implementation. Moreover public private partnerships should be encouraged so that issues
of sharing of data among institutions are made much easier. Equally the public private
partnerships would help in bridging some of the gaps that may exist in terms of resources
and expertise.
5.2.9 Socioeconomic Environment as a Determinant for the Success of e-health
The earlier studies indicate that socioeconomic environment is observed as a contributing
factor for the success of IS implementation including e-health systems (Eysenbach, 2001;
Kaye, 2010; Korpela, 2012; Hansen, 2011). The findings of the study revealed that the
improvement of socioeconomic environment is probably amongst the significant factors of
successful implementation of e-health systems. The social economic aspects that emerged
include high poverty levels, low income rates, purchasing power, digital divide, generation
gap, demography characteristics, literacy levels, equity and access, return on investment and
unequal distribution of resources. Majority of the potential users of the e-health applications
are economically challenged with low purchasing power. This means there are significant
members of the population who may not afford to buy the ICT gadgets because of the high
costs of the devices. This coupled with high IT illiteracy levels among the population may
hinder them from maximum utilization of the e-health applications.
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Generally the country is characterised by unequal distribution of resources which then
affects equity and access of the e-health applications. This is more prevalent in the rural
setting than the urban settings who are the potential users of the e-health applications
thereby creating a big digital divide among the population. Digital divide refers to those
people who have skills and knowledge on how to exploit innovations. Similarly the low rate
of return on investments of e-health systems may deter potential entrepreneurs in investing
in that area. This is because the e-health systems do not attract investment interests among
entrepreneurs as it is perceived that there are no direct benefits in e-health systems
investments as compared to other sectors. Thus the government needs to intervene to reduce
the inequities that exist between the rural and the urban population.
Furthermore the government should seek to empower their people economically so that the
poverty levels are drastically reduced which affects their purchasing power. This can be
done by introduction of income generating activities especially in the rural areas where the
poverty indices are very high. Besides the government in partnership with donors can seek
to educate the masses on what e-health is all about and the benefits of using the technology.
Consequently this way they will gradually accept technology just like they did to the m-pesa
technology thus directly impacting on the e-health implementation.
5.2.10 Legal Environment as a Determinant for the Success of e-health
An effective legal environment is regarded as a contributing factor for the accomplishment
of IS implementation including e-health frameworks (WHO, 2013; Mbarika, 2010; Ekeland,
2010; Sanders, 1995). The legal environment prevalent in most developing countries, is not
sufficiently strong in bringing up changes in the healthcare sector and in essence the
implementation of e-health systems. The outcomes show that the improvement of a
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conducive legal setting is among the fundamental elements of successful implementation of
e-health systems. The legal environment aspects that emerged include weak laws, out dated
legislations, data processing laws, e-laws lacking, enforcement issues, lack of importance of
e-laws and lack of goodwill. Majority of the respondents were of the opinion that the current
laws that guard patient’s data are obsolete while there is an absence of laws that protect
patient’s data on the network. This hinders the interoperability of the systems and sharing of
patients data on the network. Generally users of various e-health systems need to be
guaranteed that the patient’s data is protected on the network to avoid ethical issues that
guard the patient’s management. In some instances even where the law exists there is no
enforcement to compel all health institutions to report their workload thus it makes it
difficult to know exactly what is happening in the healthcare sector for planning and
decision making.
Consequently the government need to develop policies related to legal liability, ethical, and
confidentiality of the patient’s data. Furthermore an e-health policy and enabling policy-
environment are crucial to the success of e-Health solutions (Pagliari et al., 2005). Hence
there is need to develop a security policy for e-health systems. Essentially e-Health policies
should deal with e-Health maintenance and support, regulations for privacy, benefits,
cultural differences, interoperability, and capacity building. The e-government has a security
policy and the healthcare sector can customize it. Accordingly there is need of developing a
clear policy and regulatory oversight on transmission of health data and information as well.
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5.2.11 Benefits of e-health Systems
Previous studies have revealed that user’s perceived usefulness plays a key role towards
dealing with resistance of e-health systems (Akanbi et al., 2011; Ash, 2012; Ronen, 2011).
The benefits of systems include increased productivity, more accurate diagnosis, cost
reduction, assists in national planning, equitable healthcare, time saving, enhanced decision
making, efficiency and effectiveness, empowered citizens. The findings of this study
indicate that user’s perceived ease of use and usefulness of the systems are likely to be
influential in dealing with acceptance of the e-health applications which translates to
implementation of the systems. Largely the users are likely to accept systems that they
perceive as beneficial to their work as well as to the patients. Failure to which, the users
would resist the implementation of the systems. Thus the management needs to sensitize all
the stakeholders in the healthcare chain on the perceived benefits of the system way in
advance. This would prepare the users prior to implementation thus sabotage of the system
would be unlikely to happen. In this regard there is need to involve the users right from the
initial stages of the system development up to the implementation stage.
5.2.12 ICT Competence as a Determinant for the Success of e-health
ICT competence is regarded as a contributing factor for success of IS implementation
including e-health systems (Kimaro, 2005; Lazaro et al. 2013; Murray, 2010 & Kaye, 2010;
Kiura, 2012). The results from this research revealed that ICT competence is a key factor in
implementation of e-health systems. This study indicated that the number of healthcare
workers equipped for utilizing ICT in their work remains limited. Health workers are not
systematically prepared in the use of technology. Besides there are insufficient numbers of
healthcare workers with the capacity to design, deploy and oversee e-Health frameworks. In
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addition the use of ICT facilitated learning remains low in most health training institutions.
Furthermore this is made worse by the inadequate IT personnel available in the sector which
is characterized by high turnover of the staff for greener pastures.
Lazaro et al. (2013) observes that poor internet skills on the part of healthcare workers
hinders them from comprehending the difference between biased and unbiased information,
to distinguish evidence-based claims, and to interpret the information which is meant for
healthcare workers. Thus the ministry of education can introduce ICT in the curricula of all
health training institutions. Moreover training in e-health should be included in the
continuing education programs for clinicians. Largely the government should consider
establishing centers of excellence to training e-Health professionals. Equally the
organization needs to offer competitive packages that can attract and retain IT personnel
longer in the sector. Furthermore investing in capacity growth and training in technological,
communication and content development of skills will result in a more successful
implementation of e-health in the organization. Therefore it is important for the management
to allocate enough resources to support capacity building programs in the organization.
Moreover making opportunities available to see the e-health applications in practice or a
clearly reported trial should be part of the training that can help improve the user’s skills on
IT thus improving the chance for successful implementation.
5.2.13 E-standards as a Determinant for the Success of e-health
Primarily e-standards is observed as a determining factor for the success of IS
implementation including e-health systems (Braa, 2007; Juma, 2012; Lazaro, 2013 ;Fanta et
al, 2015; Korpela, 2013; WHO, 2011). The results from this study indicate that e-standards
are a key determinant in implementation of e-health systems. A standard is a settled upon,
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repeatable method for accomplishing something; it is viewed as the way to accomplishing
interoperability of e-health frameworks. E-health standards cover a wide range of spectrum
of technology; ranging from those that deal with patient data content, to electronic medical
devices (WHO, 2011). The aspects of e-standards that emerged include inadequate
standards, limited participation in standards development, lack of available standards, no
legislation exists, standards do not address one unified area of technology, conflicting and
overlapping standards, lack of importance of standards. To a great extent, healthcare systems
in Kenya are paper-based. ICT is mainly utilized to support data capturing, storage, retrieval,
and monitoring and evaluation of health programmes that are mainly sponsored by external
donors. Although the government remain a highly significant stakeholder in the healthcare
sector, there are no policies and strategies to govern e-health initiatives at national levels
(Juma, 2012).
Fanta et al, (2015) takes note that Africa for instance has no known policy framework that
governs areas of common interest at continental level. Notable in this regard is the European
Patient Smart Open Systems (EPSOS) project, which provides for the development of
interoperable electronic medical records systems across Europe in order to improve the
quality of cross-border healthcare services for its citizens. Furthermore, many of the
stakeholders do not understand the important role of standards in affecting quality care; this
is largely due to the technical nature of standardization. Moreover Braa (2004; 2007)
emphasis that for system integration and interoperability to be achieved there is need to have
standards that cover the following areas: Identifier standards: these are standards that deal
with unique identification of various entities, such as, patients, healthcare providers and
healthcare institutions. Examples of these standards include the identification of subjects of
healthcare standards and the provider identifier standard. Messaging standards: these
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standards specify the structure and format of messages to expedite secure transmission and
receipt of the messages between healthcare providers. They also specify the
acknowledgements that should be sent by the recipient of a message, as well as the warnings
that should be generated when the message has not be delivered or if it is declined.
In addition clinical terminology and classification standards need to be addressed. These
standards support the description of medical conditions and treatments using common
language in order to prevent ambiguity in the interpretation of healthcare information that is
transmitted electronically. Security and access control standards: these standards enable the
secure transmission and delivery of healthcare information so as to ensure that personal
healthcare information is protected from unauthorized access. This may be achieved by
addressing uniformity in standards development. In addition local institutions should be
equally engaged in the development of standards that meet their unique needs other than rely
on foreign standards that are difficult to meet local needs. Moreover organisations need to
set aside resources for standards development. Furthermore there is a necessity of coming up
with standards that address one unified area of technology for example e-health (Lazaro,
2013).
5.3 Interrelationships between the Core Category (implementation of e-health systems)
and other Categories
The data analysis of this study showed the interrelationships between various sub categories.
The core category was implementation of e-health systems and is mentioned recurrently
during the responses below. This core category, however, links all other categories. Figure
5.1 shows the interrelationships between the thirteen categories that emerged from the study.
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Social cultural Benefits of the
Social economic system
RR
RRR
Quality of the
Systems
ICT competence
Change
Macro political process
RR management
I Imple
n menta Actu
f al
tion
l
of use
u
e e- of
n health the
Technological Organizational
c syste syste
environment efficiency Legal
R e ms m
environment s
Online System
safety integration
E-standards
Quality of the RRR

systems
Figure 5.1: Interrelationships between Categories
Source: Author 2017.
The symbols provided below such as R1, R2...etc refer to interrelationships that have been
revealed between categories in different perspectives in Figure 5.1.
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R1. Organisational efficiency and Social cultural environment: The analysis indicated a
clear relationship between organisation efficiency and social cultural environment. If the
organisation has good will towards supporting the project it would influence the users in
changing some of their attitudes toward technology. Organisation need to focus on how they
can motivate their users to accept technology and this would have a positive effect toward
implementation of the system.
R2. Legal environment and System integration: The analysis demonstrated the effect of
improvement in the legal factors, especially those identified with system integration is
significant to guarantee there is interoperability in order to share information. Organisational
culture involves a legislative and legal environment to guarantee the sharing of data between
different healthcare institutions. Thus, the absence of an effective legal environment
concerning the utilization of system interoperability in the healthcare institutions causes a
negative effect on the sharing of patient’s data thus this hinders effective implementation of
e-health systems.
R3. Legal environment and Benefits of the systems: The analysis demonstrated the
significance of improvement in the legal environment, chiefly those linked to e-health in
order to boost trust and confidence among the users. However, the absence of e- laws
associated with confidentiality and protection of patients data on the network negatively
affect the confidence that the users have in utilising e-health systems which translates to a
negative effect on implementation of e-health systems.
R4. Organisational efficiency and Change process management: Dealing with the
change process management was found to be a crucial factor in the achievement of e-health
implementation in Kenya. Many facets of the utilization of e-health rely largely on the
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organisational efficiency supporting the process in terms of financial support,
communication, capacity building and how the aspects of change management can be as an
enabler or obstacle to the users utilising the technology. This implies that the absence of
effective change management aspects regarding implementation of e-health will affect
negatively the process.
R5. Organisational efficiency and Legal environment: The organisational culture needs
an enabling legal environment to facilitate the process of change in accomplishing the goal
of utilising the new technology. Thus, the absence of effective laws concerning the
implementation of e-health in the organisation negatively affects its implementation.
R6. Quality of e-health systems and Benefits of the systems: The analysis demonstrated a
positive relationship between the quality of e-health systems, the systems benefits and
confidence among the user. This implies that guaranteeing the e-health systems are of
acceptable quality may boost the trust among the users in implementation of the systems.
Users will only use the system if they are assured they are perfect and will meet their needs
appropriately.
R7.Macro political and Organisational efficiency: The analysis indicated the effect of
political decisions and perceptions on the implementation of e-health. Political goodwill and
enabling environment leads to effective leadership at organisation level thus this positively
affects the organisations implementation of e-health systems. An enabling political
environment acts a vital function in influencing the social and economic development for the
improvement of the population in general and in essence trying to reduce the digital divide
between the rural and the urban citizens.
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R8. Social economic and Micro political environment: The analysis exhibited the
relationship between social economic factors and micro political factors on the citizen’s
utilisation of the e-health. In Kenya for instance, the utilization of technology is mainly
found in the major towns where economical development is higher as compared to the rural
areas. Thus this makes the urban people more enlightened on new technologies or
innovations, consequently if this was cascaded down to the rural areas then everyone would
be eager to use the technology which makes acceptance and implementation of e-health
systems much easier. Thus the micro political environment plays a critical role in ensuring
there is adequate distribution of resources equitably to the entire population to reduce the
poverty levels.
R9. Quality of the system and Organisational efficiency: The quality of the system has a
direct relationship with organisational efficiency. Well designed interfaces results to the
higher quality of e-health systems. This means that good design characteristics have a direct
effect on the quality of the systems, as users are likely to accept the user friendly systems
which in turn translate to greater implementation, thus this results to a positive effect on the
implementation of the e-health frameworks.
R10. Online safety and e-standards: The analysis demonstrated a relationship between
online safety and e-standard development. This was probably amongst one of factors
determining the success of e-health system implementation. This requires the development
of standards and policies to protect the patient’s data on the network. This aspect has a
probability of impacting on the implementation of e-health systems.
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R11. Micro political environment and Legal environment: Generally the political
environment plays a significant role in the improvement of laws regarding the utilization of
the innovations. In essence this would enhance knowledge on the benefits of e-health
systems and as well as reduce the digital divide between urban and rural people which in
turn improves equity and access of e-health systems to all citizens. Indeed this would
improve the lives of all citizens. However, this effect is negative on the grounds that
political stance towards the implementation of e-health systems are not at the level required.
Moreover the inadequate legislation governing on the sharing of patient’s data on the
network may greatly affect the safety and confidentiality, thus needs to be addressed by the
stakeholders and the political arena.
R12. System integration and e-standards: There is a relationship between system
integration and e-standards. The e-standards define a minimum acceptable way of sharing
data on the network. Thus for integration to work there is need to have specific standards
that guide on the way the data is transmitted which in turn affects implementation of e-
health systems in one way or the other
R13. Social cultural values and Organisational efficiency: The analysis indicated a
relationship between social cultural values and practices and organisational efficiency on the
perception of users towards implementation of e-health systems. The culture that is
prevalent in most organisations is generally negative to technology. This is because
technology is considered an intruder to their daily work than an enabler and thus this
explains the negative attitudes that users possess towards e-health which directly affects
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R14. Micro political environment and Technological environment: The analysis revealed
that there is a direct relationship between micro political environment and technological
environment. The micro political environment plays a key role in making policies that
regulate the ICT equipment including regulating taxes on the imports. Thus this would affect
the availability of a robust ICT platform that supports the e-health systems.
R15. Micro political environment and Organisational efficiency: The analysis indicated a
relationship between micro political environment and organisational efficiency. The political
class have a hand in the choice of leadership of the healthcare institutions. Thus with wrong
choice of leadership means implementation of e-health systems may remain a challenge.
R16. Online safety and System integration: The analysis showed there is a relationship
between online safety and system integration. The stakeholders need to be assured of online
safety of the patient’s data as it is transmitted through a network from one institution to
another. Thus for integration to work security and confidentiality of the patients data need to
be guaranteed.
R17. Macro political and Social cultural environment: Macro political factors are key to
sustaining a positive social cultural environment. Political goodwill acts as a catalyst in
promoting an enabling social cultural environment. The political class have the mandate of
ensuring there is equitable distribution of resources to all the citizens in order to reduce the
ignorance, illiteracy and unemployment levels. An elite society is likely to be more open
minded and technology oriented which in turn has a direct effect to implementation of e-
health systems.
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R18. ICT competence and Social cultural factors: There is a relationship between ICT
competence and social cultural factors. Some of the users of e-health systems have high IT
illiteracy levels which cripple utilisation of the systems. Thus there is need to have
interventions done to empower users in IT skills. Users who are conversant on how to
manipulate systems are less likely to resist or sabotage the system which translates to greater
implementation of the same.
R19. Technological environment and Organisational efficiency: There is a relationship
between technological environment and organisational efficiency. Technological
infrastructure provides the platform that supports the e-health systems. The organisations
require a robust IT platform to support the implementation of the e-health systems. Without
the right ICT infrastructure in place means implementation of e-health systems in the
organisations would be a challenge. Thus this has a direct effect on the implementation of e-
health systems.
R20. ICT competence and Organisational efficiency: There is a relationship between ICT
competence and organisational efficiency. The e-health systems require personnel to operate
thus it is very critical for each organisation to have the right IT personnel in place to support
these systems. The entire users in the organisation also need to have basic skills on how to
utilize the systems. Hence the organisation needs to factor issues of short ICT sensitization
in their planning. This has a direct relationship in e-health implementation.
R21. Social cultural environment and Organisational efficiency: The analysis showed
there is a relationship between social cultural environment and organisational efficiency on
the implementation of e-health. Confidence in e-health frameworks requires trust both in the
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organization and in addition confidence in the technology, where users are guaranteed that
the frameworks can address their issues successfully. Thus it is necessary to build trust
between the users and the organization so that implementation may be made much easier.
R22. Sociocultural environment and System integration: The analysis revealed that there
is a relationship between the sociocultural environment and the system integration. Culture,
for example, resists change. The integration of various e-health systems affects user’s
responsiveness to utilisation of the e-health systems. However system integration may not be
successful because of the user’s cultural hindrances. This is on the issues of fear of sharing
of patient’s data online where issues of security and confidentiality emerge and thus affects
R23.Technological environment and implementation of the e-health system: The
analysis indicated that the effect of improvement of technological infrastructure platform on
the effectiveness of e-health. The stability in the infrastructure platform in dealing with
aspects of reliability, availability, accessibility, affordability and maintenance is among the
main reasons that positively influence implementation of e-health in the country today.
R24. Social cultural and Micro political environment: There is a relationship between
social cultural factors and micro political factors. There is a major divide in the population
in terms of access and literacy levels. Some members of the population are relatively poor
thus they may not be in apposition to afford the ICT gadget to access e-health applications.
In addition the IT literacy levels are fairly low so utilization of the systems would be a
challenge. Therefore the more economically challenged the users are, the more likely they
are to resist, sabotage and fear implementation of technology as this comes with a cost
aspect. Thus this may have an effect of the implementation of e-health systems.
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5.4 Final Categories
The thirteen categories discussed above were analysed further through selective coding and
reduced to five fundamental themes or points of view in particular: political e-readiness,
managerial practices, IS Capability, societal e-readiness and regulatory framework
viewpoint. This integration among the five viewpoints gives clarification as to why many
developing countries have not been fruitful in implementation of e-health frameworks
appropriately. In any case, the analysis demonstrated that the achievement of e-health with
regards to developing countries by and large and Kenya specifically is not a simple
undertaking since it relies on upon a multifaceted blend of variables. The purpose of
amalgamating the categories according to the researcher is based on the need to generate an
integrated framework that explains the issues that underlie implementation of IS, especially
e-health systems. In any case, these factors differ depending on the environment, in which e-
health systems are being implemented.
5.4.1 Managerial Practices
Figure 5.2 demonstrates the managerial practices category, and their related concepts that
are likely to influence the implementation of e-health systems. The categories that were
grouped together to form the managerial practices include change process management,
political e-readiness, organisational efficiency and ICT competence. The analysis indicated
that the effective managerial practices in the organisation play a significant role in the
successful implementation of e-health (Anwar, 2012). Fundamentally, the organisation
usually coordinates functions related to planning, organising, coordination, implementation
and management of e-health systems, thus it has to facilitate the process of change
management as well as ensure that there is capacity building in the organisation (Boonstra et
al., 2014). This equips the users with the necessary skills needed to utilise the systems as
well as manipulating user’s perception towards implementation of e-health systems.
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Inadequate or unsustainable funds were cited as a major hindrance to e-health
implementation (Ronen et al., 2011). In the long term, donor funding may present a
challenge for sustainability of e-health projects. Furthermore in endeavouring to scale-up e-
health systems, programs may be disadvantaged by dependence on donor funding hence
there is need for transiting to alternative and varied resources. Consequently the political
environment plays a critical role on allocation of more resources to the various healthcare
institutions (Avgerou, 2008; WHO, 2013).
However well organised, in practice, IS may face failure especially when the aspect of
human element is neglected. In most instances the human element is ignored and roles are
not allocated in the process. Generally there is no framework that does not work without the
existence of users that comprehend the framework, its significance and after that utilizing it
(Fanta, 2015). Basically, if the e-health system is perceived as an information system which
it is, the success of the system needs the involvement of users in different ways thus change
process management is very critical in the organization. Besides this would play a great part
in sensitizing the users (Juma et al., 2012).
Among one of the outstanding issues emerging from effective managerial practices is the
organisational politics that are dominant in the institutions where personal interests override
the organisations interest. Thus change process management is significant in sensitising the
stakeholders on the importance of e-health systems thereby demystifying the perception
stakeholders have towards the systems. Similarly this would assist in ensuring there is
continuity of the e-health projects initiated in case there is change of leadership. In essence
supporting the IS leadership in the organisation. Besides such users would be the champions
of the e-health project in the organisation. Moreover involving the users in the change
management means there are less likely to resist technology thus the effective managerial
practices plays a fundamental role, which would positively or negatively touch on the
success of e-health implementation in the healthcare sector in Kenya (Qureshi et al., 2013).
212
Attitude towards Stakeholder’s
change involvement
Continuity Resources for

plans change
IS leadership
Advocates for
change
Change process
Stakeholder’s management
IS leadership Commitment
involvement
Bureaucratic Champion
procedures for change
Absence of Public
private partnership
Implementat
Actual
use of
Innovativeness Managerial ion of e-
the
orientation
systems
health
practices
Conflict of
interest systems
Strategic
orientation
Self interest ICT competence

Basic Skills
lacking
Inadequate Shortage of skills in

Political e-readiness expertise health informatics
High ICT personnel Qualified technical

turnover team
Policies & Political

laws goodwill
Figure 5.2: Managerial practices, and their associated attributes that are likely to
affect the implementation of e-health systems
213
5.4.2 IS Capability
IS Capability plays a key role in the implementation of the systems. IS capability includes
resources such software, hardware, communication, IT personnel and IT applications which
are inimitable, unique and consequently can be used to support and sustain the e-health
systems (ITU, 2015). The IS capability concept has also been used by Peppard and Ward
(2004) who refers to IS resources as business resources, technical IT resources and human
competence. They propose that these three attributes have to work together for the success
of IS capability to be realized. Basically for implementation of e-health to be achieved there
is need for the organization to exploit its IS resources properly.
The categories that were grouped together to form the IS Capability category include system
quality, system integration, e-standard, online safety and technological environment.
Undoubtedly an often mentioned example of a weak ICT infrastructure platform is
inadequate network infrastructure and connectivity. Primarily lack of network infrastructure
can result in a set of security flaws, while others are lack of backup mechanism (Anwar,
2012). Moreover technical resources such as on-site computers and computer systems are
inadequate as well. Hence key to e-health implementations is the delivery of the right
information, at the right place and at the right time. It is vital to keep a core dataset that acts
as a point of comparison for data accuracy and user traceability. Such include audit logs of
user activity, page viewing and editing. The utmost straightforward solution to address
interoperability issues is the setting of national e- standards. (Braa, 2007; Mbarika et al.,
2012; Korpela, 2013).
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In addition for the e-health to work, online safety is very important. This will assure users of
safety of the data being transmitted over the network as well as supporting system
integration which is necessary for interoperability to work (WHO, 2013). Int this case for
integration to be feasible the systems have to have certain desired qualities. Thus e-standards
will provide an enabling environment for safety to be enforced on the network which in turn
supports integration (Kimaro, 2007). The e-standards provide a uniform platform on how
data is to be transmitted over the network which is a necessity for success of e-health
implementation (Qureshi et al., 2013).
215
Synchronisation
Available issues
Reengineering
Accessible of internal
processes
Interoperability
issues
Responsive
System quality
Integration btn
Online support System integration donor and other
systems
Integration btn
Inadequate
Poor national county and
hardware ICT national systems
and software infrastructure
Capacity for
information
processing
Interruption Actual use

of internet
service IS Capability Implementation of the
of e-health systems
Affordability
systems
Obsolete
technology
Poor
definition Risk assessment
of user’s
roles Online safety and
Local security Authorization
participation in
development of
standards
E-standards Controls
Uniformity in
the standards Information
protection System audit
E-health
standards devt Information Internet
Overlapping and security safety
contradicting
standards
Figure 5.3: IS Capability, and their attributes that are likely to affect the
implementation of e-health systems
Source: Author 2017
216
5.4.3 Political e-readiness
E-health readiness means the preparedness of healthcare organizations or communities for
the expected change caused by plans associated with ICT-application. In other words e-
readiness is referred to as the facility and capability to follow value creation chances assisted
by the utilizing the Internet. In this case the community’s capability to support and sustain
the development of ICTs in healthcare (Qureshi, 2013). Political e-readiness as a concept
here refers to the preparedness of politicians in the willingness to support and sustain e-
health systems by word and action. The political arena is characterized by lack of good will
towards implementation of e-health systems coupled with self interests that override the
larger society good. This concept has also been discussed by Beebeejauna and Hemant
(2017) who refers to political e-readiness as key in dealing with policies and legislations that
promote, support and manage e-health implementation and utilization in the healthcare
sector.
A conducive political environment is very key towards implementation of e-health. The
categories that were grouped together to form the Political e-readiness include legal
environment, organisational efficiency and e-standards. Political goodwill will lead to better
organisational leadership. Organisational leadership is charged with carrying out functions
such as planning, coordination, controlling, and directing various aspects of e-health
implementation. Thus it is appropriate to have a stable focused leadership that can steer the
implementation of the project. Political goodwill will promote equitable distribution of
resources between the rural and the urban healthcare facilities. Besides it will also promote
an enabling legal environment for enactment of laws and standards which in turn translates
to success of e-health implementation (Oladosu, 2009; Mbarika, 2012; Murray, 2010).
217
The purpose of e-standards in e-health is seen in the healthcare organizations as the driving
force behind the technology platform that supports interoperability of the systems. A
standard is a settled upon, repeatable method for accomplishing something. Fundamentally it
is viewed as the key to accomplishing interoperability of e-health systems. Any individual
organization or project involved in e-health applications has to make its own decisions
concerning official standards, actual standards, and proprietary solutions (Korpela, 2014 &
Juma, 2012). Thus the political e-readiness plays a significant role in ensuring that the right
laws and legislations are put in place to support the e-standards development. Basically IS
leadership is lacking in the political field. There is need to have a champion in place who
would advocate and steer the process of e-health implementation in the country.
Consequently there is need for creating awareness among politicians, regarding e-health, to
acquire more support for e-health programmes in particular. This may be done in terms of
advocating for policies and resources that support the program.
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Uniformity in the E-laws
Local participation lacking
in development of standards Out-dated
standards legislations
Enabling Legal
Ehealth standards Enforcement environment

issues
E-standards
Low good will
Overlapping in support of
and laws
contradicting
standards Legal environment
Lack of awareness
of important laws
Corruption
ROI of IT
investments Low Political
good will Data protection
laws
Inadequate
funding
Policies and
strategies Implement Actual
Political e-
ation of e- use of the
Poor
collaboration readiness
between partners health systems
Conflict of
systems
interests
Economic
development
Absence of Public
private partnership
Strategic
orientation Organisational
efficiency
Bureaucratic
IS leadership procedures
lacking
Innovativeness
Conflict of orientation
interest
Top management
Self interest & support
organizational
politics
Figure 5.4: Political e-readiness, and their associated attributes that are likely to affect
the implementation of e-health systems
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5.4.4 Societal e-readiness
E-readiness refers to the degree to which a society is prepared to participate in the
Networked world. It is gauged by assessing the societies relative advancement in the areas
that are most critical for ICT adoption and in this case the implementation of ICT in the
healthcare (Qureshi et al., 2014). Khoja et al. (2007) further discusses this concept as the
preparedness of healthcare institutions to implement programmes that involve use of
Information and Communication Technology (ICT) in provision and management of health
services. The societal e-readiness dimension deals with an organisation’s socio-cultural and
economic issues related to e-health implementation. This includes the stakeholder’s ability
to utilize the systems including attitude, culture, purchasing power, training and skills.
Societal e-readiness concept has been used by Li and Seale (2012) who elaborates on the
need of having societal e-readiness in place that deals with the organisation’s socio-cultural
and economic issues related to e-health implementation. Additionally Jennett et al. (2003)
mentioned e-societal readiness as the degree to which users and the health care organization
itself are prepared to participate and succeed in implementation and utilization of e-health
applications.
Qureshi et al., (2014) further notes that developing countries require not only a transfer of
technology but also needs to focus on the culture of users in using these IS systems. The
implementation of e-health, therefore, is not limited to the adaption to machines, hardware,
software, but also involves the stakeholder’s behaviors and competence. Typically the
implementation of the e- health systems requires involvement of all the stakeholders, thus
users play a key role towards its success. The categories that were grouped together to form
the societal e-readiness include; social economic factors, political environment, social
cultural environment, benefits of the system and organisational efficiency. Ideally the
relationship between the social cultural and economic aspects directly impacts on the
organisation’s success of implementation of the systems (Oladosu, 2009b). Thus the

220
managerial practices in place need to be effective dealing with the cultural issues so that the
users cannot sabotage the process which leads to a positive or negative effect towards the
implementation (Hedstrom & Andersson, 2012).
Typically little confidence levels of ease in utilizing of technology may have to do with
issues such as fear of computers. Moreover there could be technological concerns such as
perception of risk, including concerns about security, validity and reliability of the
technology, as well as privacy, safety and discretion concerns (Hansen, 2011). Furthermore,
Bhatia (2014) notes that a significant potential barrier to implementation might not
essentially be technological intricacy, but could be job losses apprehensions. In addition
limited user involvement in the system development appears to be a great contributor to
failure of e-health systems (Treurnicht, 2009). Besides for the users to deal with their social
barriers they need to appreciate the benefits that they are likely to gain from utilizing the
systems more so in their line of work (Korpela, 2012). Ultimately once they perceive the
systems to be beneficial to them then they are likely to support implementation.
In addition the stakeholder’s purchasing power comes into play as this is quite significant in
their ability to acquire the ICT gadgets. Low purchasing power may hinder the stakeholders
from accessing and acquiring the electronic gadgets which in turn leads to low uptake of e-
health systems. Furthermore the electronic gadgets need to tackle the key determinants of
accessibility to e-health systems pertinent to their environment, along with other major
planning issues such as needs assessment, execution, and evaluation. Besides in order to
solve the digital divide among the stakeholders there is need to permit greater access to e-
health systems for various stakeholders of different genders and socioeconomic groups.
Moreover a conducive political goodwill will ensure there is equitable distribution of
resources which solves the challenge of inadequate resources or increased poverty levels.
This in turn influences the users in utilising technology easily (Akanbi et al., 2011: Kiura,
2012).
221
Unequal distribution
of resources Equity and
access
Political good Digital
divide
will
Demographic
Macro Political
Conducive characteristics
environment
political
Social economic
environment
factors Low income rate
Sabotage Poverty levels
Fear
Literacy levels
Threat to privacy
Depersonalisation
Unemployment
Implement
ation of e- Actual use

Societal e-
Corruption
health of the
readiness systems systems
Low e-health
culture
Low good
will users Time wasting
and interference
Absence of Public
private partnership
Organisational
Improved efficiency Bureaucratic
decision making procedures
Healthier Innovativeness
people Strategic orientation
orientation
Benefits of the e-
Increased health systems Top management
productivit support lacking
y IS leadership
Real time Conflict of interest
lacking
Equity treatment
&access
Figure 5.5: Societal e-readiness, and their associated Concepts that are likely to Affect
the Implementation of e-Health Systems
Source: Author 2017
222
5.4.5 Regulatory Framework
The implementation of e- health requires an enabling regulatory framework. This includes e-
laws and regulations, e-standards, e-policies (Sanders, 1995). An effective regulatory
framework will facilitate fast tracking of laws and policies that protect the e-health
transactions on the network (WHO, 2013). There is a relationship between the legal and the
political factors as they directly impact on the organisation success of implementation of the
systems. The political environment has a responsibility to pass laws and fast-track the
process of their implementation. Basically with the right laws in place then the organisations
can champion the implementation of the systems (Ekeland, 2010). Besides the laws would
also help to deal with some cultural issues of online data security as well as sort the issues of
systems integration which are all aspects that may affect the implementation (WHO, 2011).
One of the major hindrances to systems integration and sharing of data among institutions is
lack of e-laws that can support this process. The users of e-health systems need to be assured
that the patient’s data over the network is protected and confidentiality is assured. This may
increase the confidence levels among the users which directly increases user’s acceptance of
the systems which in turn translates into greater implementation of the systems (Qureshi,
2014). Thus e-standards are critical in ensuring there is uniformity in the transmission of
data online. Similarly laws need to be put in place that compels organisations to report their
patient’s data to the District Health Information Systems (DHIS). This would compel all
healthcare institutions both private and public to report their workload. This would assist in
national planning for disease trends and patterns. In addition penalties and enforcement
should be introduced at organisational levels for those who fail to abide by the laws.
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Policies and
strategies Poor collaboration
between partners
Corruption
Conflict of
interests
Low Political good
will
Low good will

in support of
Macro political laws
factors
Lack of awareness and Enabling
importance of laws
environment
Data protection
laws
Low good will

in support of
laws
Regulatory Implementa Actual

Enabling Legal
environment tion of e- use of the
Framework
health system
E-laws
systems
lacking
Enforceme
nt issues Out-dated
legislations
Absence of
Public private
partnership
e-standards Strategic
orientation
Organisational Bureaucratic
efficiency procedures
IS leadership
Low lacking
Uniformity participation Innovativeness
in on stds devt Conflict of
orientation
standards interest
Too many Top

standards Politics and
corruption management
support lacking
Figure 5.6: Regulatory Framework, and their Associated Attributes that are likely to
affect the Implementation of e-health Systems
224
e-laws
ICT competence
Change
process Regulatory
management framework
Managerial E-standards
Benefits of
practices
the system
Implementation
Online of e-health
safety and
security systems Social
cultural
IS
System Capability Societal e-
integrati
on readiness
Social
economic
Quality of the
systems
Political e-
readiness
Legal
e-standards environment
Organizational
efficiency
Figure 5.7: Concept Diagrams showing the Emergence of the Five Main Themes from
the Thirteen Sub categories
Source: Author 2017
225
5.5 The Final Conceptual Model
Based on the analysis of the results and the supposition of interrelations among the themes, a
theoretical model was developed that explains implementation of e-health in the healthcare
sector in Kenya. The final model generated a theory that explains implementation of e-
health in the healthcare sector in Kenya. According to Strauss and Corbin (1994) theory
consists of “plausible relationships proposed among concepts and sets of concepts. Without
concepts, there can be no propositions, and thus no cumulative scientific knowledge based
on these plausible but testable propositions” (p.278).
The final conceptual model is comprised of five main perspectives namely; political e-
readiness (policies, laws and regulation) Oladosu, 2009; Mbarika, (2012), managerial
practices (change process management, ICT competence, benefits of the systems) Boonstra
et al., 2014; WHO, (2013) IS Capability (system integration, online safety and security,
quality of the systems) ITU, 2015; Korpela, 2013; Qureshi et al., (2013), societal e-readiness
(social economic social cultural, benefits of the systems) Bhatia 2014; Akanbi et. al 2011:
Kiura, 2012; Braa, (2007) and regulatory framework (e-standards, e-laws) Ekeland, 2010;
WHO, ( 2011), effectively as shown on Figure 5.8. All these factors influence the
implementation of e-health in the healthcare sector in Kenya today as reasoned out below.
Political e-readiness has a positive effect on the managerial practices and IS leadership.
Political e-readiness leads to effective organizational leadership. Thus with this in place
organizations are bound to champion for the change process management that in turn
influences on how e-health systems are implemented. Similarly the political e-readiness is
equally significant in the allocation and distribution of national resources equitably. Thus
this goes a long way in resolving the social economic issues of the users of the systems.
226
Additionally IS Capability provides the platform on which e-health systems run both in
terms of infrastructure and personnel. Consequently without a robust infrastructure in place
then issues of connectivity, reliability, interoperability, and accessibility will not be possible.
Typically societal e-readiness has a direct effect whether positive or negative on the
managerial practices. Fundamentally the users of the system are key to the success of e-
health so if their attitude is negative they are bound to resist change or sabotage the process.
Moreover resistance to change may be detrimental to the implementation of e-health as users
are one of the main components of information systems. In addition change process
management need to be carried out properly so that each stakeholder is involved in the
project as this would eliminate the resistance aspect. Moreover top management support
would be critical in allocation of resources to support the change process management and
acquisition of the infrastructure that provides a platform for the information system.
Furthermore for integration and online safety of data to be feasible there should be e-laws in
place that protect and support the interoperability and online transactions. Therefore all these
factors are intertwined without which e-health implementation would not be a success.
227
Actual use of the
system
Regulatory Societal e-readiness

framework  Attitude
 Laws and Influences Implementation Influences  Culture
regulations  Economic ability
 E-Policies of e-health  Training/skills
 E-standards
systems
I
I n
n fl I
f u n
l e f
u n l
e c u
n e e
c s n
e c
e
s
s
Political e-readiness Managerial practices IS Capability

 Connectivity
 Political goodwill  Change process  ICT competence
 Enabling political
management  System integration
environment.  Top management  Online safety
support  Robust
 IS leadership Infrastructure-
 Organizational (hardware&
politics software,
 Self- interests communication)
Figure 5.8: Final Framework of the factors that affect implementation of e-health
systems that is grounded from data
228
5.6 Comparison of the New Framework with other Existing Frameworks
The framework presented on figure 5.8 provides five elements that need to be addressed for
successful implementation of e-health systems in Kenya to be accomplished. These elements
include IS Capability, managerial practices, regulatory framework, societal e-readiness and
political e-readiness. Extensive literature review done at the beginning of the study indicated
five issues that needed to be addressed mainly: e-Health standards; ICT and e-health
policies; e-legislation; e-Health infrastructure; ICT competence. However these five issues
only constitute two of the factors of the current framework that is, IS Capability and
regulatory framework, consequently there was an addition of three other issues that emerged
from the data, that is political e-readiness, managerial practices and societal e-readiness.
Generally the other existing frameworks tend to address just a few aspects presented in the
new framework. For instance Braa (2004, 2007) framework addressed the issue of e-
standards leaving out other aspects that may influence implementation. Although Korpela’s
(2013) framework was more focussed on the healthcare specialists, system users and
developers it ignored other aspects of implementation that includes the political e-readiness
and managerial practices. Other frameworks ( Juma et al., 2012; Xiangzhu et al., 2013;
Kaye, 2010; Mugo et at 2014; Mbarika et al., 2012; Kiura, 2012; Lazaro et al., 2013; Fanta,
2015) were not holistic and only addressed discrete bits of the elements that may affect
implementation of the e-health systems.
The new framework developed above is grounded from the data that was gathered from
respondents. Basically the framework offers greater scope or coverage of e-health issues
compared to other existing frameworks. It is more holistic in nature and presents the real
context of developing countries and more so the case of the Kenyan healthcare sector. This
would provide a basis for successful implementation of e-health systems in developing
countries similar to Kenyan context.

229
5.7 Chapter Summary
This section introduces the summary of the review after data analysis. The conceptual model
presented in Figure 5.8 summarizes the significance of applying grounded theory
methodology. A theory was developed that best explains the issue of e-health
implementation in developing countries and specifically Kenya. An inclusive and integrated
framework of the development of categories, concepts and their properties of the issue that
was being explored was thus presented. This model clarifies the issues that should be
addressed for fruitful implementation of e-health systems in developing countries like Kenya
to be achieved.
The findings of the study showed various other elements that affect implementation of e-
health frameworks that were not included in the literature review. Five issues emerged from
the extensive literature review done. In contrast the data driven study came up with thirteen
categories. These were later reduced to form five larger categories. The study generated
three new categories not included in the earlier literature review namely political e-
readiness, managerial practices and societal e-readiness. The five factors found in the
literature review were only part of the two factors namely regulatory framework and IS
Capability generated. Therefore a data driven methodology provided a deeper understanding
into the field of study. Generally the approach was able to explore the underlying issues in
detail thereby generating information that would not have been otherwise available in a
theory testing approach. Thus this methodology provided a suitable dimension of
understanding the e-healthcare better as opposed to theory testing approach. The findings
were grounded from the respondents experiences thus providing an opportunity to gather as
much data as possible that is helpful in dealing with e-health implementation challenges in
the country.
230
CHAPTER SIX
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
6.1 Introduction
This chapter provides the summary, conclusion, recommendations, contributions and
limitations of the study. The purpose of this research was to find out the factors that are
relevant towards successful implementation of e-health in the healthcare field in Kenya.
6.2 Summary of Findings
The main goal of this thesis was to conduct an exploration of the elements that affect the
implementation of e-health systems in Kenya’s healthcare sector. To address the problem of
this study, the researcher formulated a research question: which was, what are the factors
that add up to the successful implementation of e-health systems in Kenya and how are they
interrelated?
The study began by conducting an extensive literature review in the field of healthcare
sector in general and Kenya in particular. Five issues emerged from literature review
mainly: e-Health standards; ICT and health policies; e-legislation; e-Health infrastructure;
ICT competence. These five issues stood out significantly in the e-health literature as
elements that affect implementation of e-health in general. This formed a starting point of
this study. Pragmatism philosophy was used for this study. Pragmatism allows the
researcher to use the most suitable method to understand the problem being investigated. In
pragmatism paradigms are not seen as abstract entities with timeless characteristics but
rather perceived as ever changing belief systems. They are means of doing research rather
than means of defining the ontology and epistemology underpinning research. Thus this
231
philosophy emphasis on whatever works to meet particular needs of the researcher instead of
restricting the researcher to explicit methods in answering the research question (Scott and
Briggs, 2004; Morgan, 2007). As such the researcher adopted a theory building approach to
explore the factors that affect implementation of e-health in Kenya. Grounded theory
approach was embraced as the methodology for this research.
Grounded theory is an inductive approach that allows researchers to generate theories
directly from raw data and maintains data to be grounded rather than forcing data to fit with
existing theories thus fostering creativity. Grounded Theory does not start with testing
existing hypothesis but utilizes the empirical data to produce the theory (Charmaz, 2014).
The Straussian version of Grounded theory was adopted for this study. This version of GT
allows the researcher to begin with doing some literature review in the area of study in this
case e-health implementation and this forms a baseline of the data collection (Strauss &
Corbin, 2015).
However the mind of the researcher remains open even as she approaches the data collection
allowing ideas to flow freely. The researcher is thus able to collect rich thick data that
makes the world appear new (Charmaz, 2006). The researcher embraced theoretical
sampling to interview a total number of 30 key stakeholders in the healthcare sector who are
involved in ICT implementation in the sector. In this study saturation was attained with 22
interviews. However the researcher went ahead to interview 8 other respondents with the
hope of finding new data concepts.
Nvivo software version 11 was used to assist in the analysis of the data. Data analysis began
with transcribing of the audiotaped interviews. This was followed by three stages of coding
namely open, axial and selective. In open coding the interviews are analysed and coded
232
using the segments word by word and line by line. Theses sections of the analysis were later
called occurrences. At this stage the researcher was trying to recognise activity verbs for
each bit of the data. Consequently initial categories started to appear after several interviews.
The initial concepts and categories were equated with other segments of the data to establish
theoretical relevance. 158 concepts were generated at this stage. Each of the concepts were
coded by sub categories and their properties. Word trees were used to visualise results in a
tree like diagram. Word trees show the context surrounding categories from across the data
and discover recurring themes and phrases that surround a category of interest.
Explore diagrams assisted the researcher explore the connections between the concepts
visually and how they relate to the central category. The central category in this case was
implementation of e-health systems in Kenya. Memos were written through out the study.
These are notes and ideas linked to the codes and their relationships that appear during the
coding process. Memo writing assisted the researcher to write down notes on the developing
categories and the relations between them. In addition literature review was another source
of data that the researcher used to fuse into the theory.
At axial coding data was put back together in new ways after open coding by making
connections between categories. At this stage thirteen subcategories were generated which
included quality of e-health systems, benefits of e-health systems, macro political
environment, sociocultural environment, online safety and security, e-standards,
technological environment, change process management, systems integration, ICT
competence, organisational efficiency , socioeconomic environment and legal environment.
The emergence of the thirteen categories was supported by extracts of interview scripts from
the responses.
233
At selective coding the researcher sought to integrate and develop the theory by creating
relationship among the categories. The core category in this case in point is implementation
of e-health system. The thirteen sub categories that were generated in axial coding were
assembled into 5 key categories of view namely: political e-readiness (policies, laws and
regulation), managerial practices (change process management, ICT competence, benefits of
the systems), IS Capability (system integration, online safety and security, quality of the
systems), societal e-readiness (social economic social cultural, benefits of the systems) and
regulatory framework (e-standards, e-laws) viewpoint.
The amalgamation of these five viewpoints affects the accomplishment of implementation of
e-health frameworks in Kenya. Finally a new framework was developed that consisted of
these five categories. Namely: political e-readiness, regulatory framework, managerial
practices, societal e-readiness and IS Capability that were grounded from empirical data.
The new framework may explain e-health implementation in developing countries.
6.3 Conclusion
This study set out to identify the factors that hinder successful implementation of e-health in
Kenya. The researcher embarked on filling the gap using a holistic approach and developing
an integrated framework. The study developed a theory rather than test existing theory. The
study generated five major themes namely political e-readiness, regulatory framework,
managerial practices, societal e-readiness and IS Capability. A framework was developed
that that is holistic, detailed and grounded from data. The model is easy to implement as it
represents the healthcare context at it is. It reveals the factors and their interrelationships
from five main perspectives, namely; political e-readiness (policies, laws and regulation)
managerial practices (change process management, ICT competence, benefits of the

234
systems), IS Capability (system integration, online safety and security, quality of the
systems), societal e-readiness (social economic social cultural, benefits of the systems) and
regulatory framework (e-standards, e-laws) effectively. All these factors are interrelated and
intertwined. For the implementation of e-health system to be successful all the factors have
to be integrated together.
Conducive political e-readiness determines the kind of laws and policies that are put in place
to support the systems. In essence political good will lead to efficient managerial practices
and leadership. Thus with this in place change process management will be enhanced as well
as breaking the bureaucratic structures that hinder progress of the e-health project. In
addition political e-readiness will ensure there is equitable distribution of resources thereby
empowering people economically and increasing their purchasing power thus sorting the
societal e-readiness. Furthermore political e-readiness may steer the process of developing
laws and regulations that support systems integration and data sharing as well as create
legislations that support public private partnership initiative in the sector.
Effective managerial practices are key to the progress of the e-health project. Top
management support would steer the project to success by facilitating the funds needed for
the implementation of the e-health project. Ideally with adequate funding in place there will
be a robust infrastructure to support the implementation. Moreover good organizational
leadership would champion the e-health project to greater heights by capacity building to
break the social cultural barriers as well as attract and retain the best IT professionals to fast
track the project. In addition the organization may initiate IS leadership and the change
process management so that users can easily accept the innovation. Indeed with top
management support the users are unlikely to resist introduction of technology or even
235
sabotage it. Besides effective managerial practices plays part in promoting continuous ICT
training programs for the workers. This would equip them with the necessary skills to utilize
the systems, which in turn translates to greater implementation of e-health systems.
Moreover user resistance was cited as a major barrier in implementation of the e-health
systems as users tend to resist its usage because of lack of ICT skills. Furthermore
inadequate ICT skills may hinder full exploitation of the e-health systems. Thus training
may go along way in solving the problem of user resistance to technology.
IS Capability are also crucial in the achievement of e-health systems. This is because it
provides the platform on which the system runs. Thus there is a need of having adequate
infrastructure in place for the technology to be utilized properly by all players on the
healthcare chain. Besides system integration among organizations can only be possible if
there are laws in place that support that integration. Moreover organizations need to be
guided by laws in order to report their data. In the absence of laws it would be difficult to
compel unwilling parties in the healthcare chain to cooperate in sharing patient’s data
online. In addition for integration to work the social factors such as economic and cultural
issues need to be addressed so that data can be exchanged on the network. For instance
poverty plays a big hindrance to acquisition of ICT gadgets that may be used by users to
access e-health application like m-health. Therefore users need to be empowered
economically.
The societal e-readiness empowers the users of the system both economically and
knowledge wise. Thus the political e-readiness may play a part in ensuring there is equitable
distribution of resources among all citizens. Basically the users need the purchasing power
to buy the ICT gadgets that they may need to access certain e-health applications. By and
236
large Internet connectivity is a necessity to most of the consumers. Thus political e-readiness
may play a part in ensuring there is equitable distribution of resources among all citizens.
Moreover they need to regulate laws that may reduce taxes on imports of the ICT equipment
to make them available to the general public.
Generally the regulatory framework is essential in providing e-laws that support e-health
implementation. For instance for system integration to work, there is need to have e-laws
that guard patient data on the network. Ideally these laws ensure confidentiality and security
of patients data on the network is guarded. Besides in the absence of these laws system
integration and sharing of patient’s data may not be possible. Furthermore the laws will
guide on the e-standards which each player in the healthcare chain is to abide by.
Consequently the political e-readiness plays a significant part in fast tracking of these
policies and laws.
In conclusion the researcher found that the issue of successful implementation of e-health
needs to be addressed holistically so that all the stakeholders are engaged in the project. The
five main issues that are grounded from the data are intertwined and inter related thus there
is need to address them holistically for e-health implementation to be effective.
6.4 Implications of the Study
This section presents the key contributions made by this study to the field of academia,
theoretical, methodological and practical implications for research.
237
6.4.1 Theoretical Contribution
First theoretically, the adopted theory building methodology aimed at identifying the
elements and their interrelationships that affect implementation of e-health systems from a
grounded theory viewpoint thereby generate a theory (theory building). Most previous
studies were positivist oriented which are intended to identify the factors that affect
implementation of e-health systems by adopting theories and empirically testing the theories
unlike this study that is data driven. This study generated a substantive theory that can be
adopted to explain e-health implementation issues in a developing country context especially
in Kenya. This is supported by Charmaz, (2001) who emphasis that Grounded theory gives
preference to data and the subject being explored as opposed to the earlier hypothetical
suspicions. With GT, theory is originated and created by the field of study, and emerges out
of the exact data gathered from it. According to Charmaz, (2011) the grounded theory
method offers “a logically consistent set of data collection and analysis procedures aimed to
develop theory” (p. 245). These methods permit the recognizable proof of examples of data,
by examining these examples researchers can determine hypothesis that is exactly
substantial to the issue being explored (Strauss & Corbin, 2015).
6.4.2 Contribution to Knowledge
This study makes a contribution to existing body of knowledge in regard to the process used
in applying the methodology of pragmatist grounded theory approach to develop an
integrated model for e-health implementation for this research. This study was intended to
connect existing gap in information on the implementation of e-health frameworks in
developing countries generally and Kenya specifically from the perspective of IS. As needs
be, this exploration adds to filling the knowledge gap in past studies. The study generated a
new model that explains the issues that need to be addressed for successful implementation
238
of e-health systems. This model is more holistic than the existing models as it introduces
categories that are not addressed in the existing models (Braa, 2007; Korpela, 2013; Juma et
al., 2012; Xiangzhu et al., 2013; Kaye, 2010; Mugo et al., 2014; Mbarika et al., 2012; Kiura,
2012; Lazaro et al., 2013; Fanta, 2015). The framework increases in expansion from the two
original issues to five that have been generated from the data.
6.4.3 Methodological Contribution
The application of the grounded theory in the analysis of e-health implementation meets the
grounded theory explanatory power leading to generation of a substantive theory. The
grounded theory methodology allowed open exploration depicting development of concepts
showing their relationships and development of substantive theory that may be used to
explain e-health implementation issues in Kenya. Most of the other IS studies in healthcare
research use positivist approaches that have a bias that forces certain preconceptions unlike
Grounded theory approach that allows theory to emerge from data. This study is significant
as a pioneer in theory building in IS in Kenya and in the IS healthcare research using
grounded theory. As such other scholars can draw from this pioneering study.
6.4.4 Contribution to Policy
This research has noteworthy ramifications for practice, and could give some prescriptive
bearings to policy makers in developing countries, and an inspiration to implement e-health
frameworks. Other than the general ramifications for the government and the research
community, multinational organizations and non-governmental organizations interested in e-
health ventures could better comprehend the factors impacting the implementation of e-
health systems. Additionally these findings may guide the stakeholders in better policy
formulation and improvement of e-health strategies in regard to the field to e-health
implementation.
239
6.4.5 Contribution to Practice
This research provides decision-makers, and all the stake holders in the healthcare sector,
with a key instrument through which they can survey the effective implementation of e-
health frameworks from a comprehensive perspective. This would add to the comprehension
of key issues that should be addressed for the implementation to be fruitful. Besides the
most critical ramifications of this exploration is it has offered healthcare stakeholders a
guidance that can be vital in executing e-health systems in Kenya.
The usability and success of the framework for developing countries is underpinned by a
mind-set which recognizes the national politics among key determinants within the social
structure of any project, of which e-health form part of. Moreover a significant contribution
of the framework to information systems research is its recognition of IS Capability,
managerial practices, political e-readiness, regulatory framework and societal e-readiness
that influence or mediate the success of e-health implementation in the country. In addition
the framework contributes to a better understanding and knowledge of Information System
implementation in developing countries in general. This provides a foundation for
information system professionals and consultants to improve on their professional practice
especially in the area of e-healthcare research.
6.5 Recommendations
The researcher recommends that the Government of Kenya adopt and use the findings of
this study to implement the e-health policy as well as improve on the existing one. Likewise
both the County and the National Government can use these findings to implement e-health
systems and improve on the already existing applications in their healthcare facilities.
240
Besides the methodology used for the study was informative and detailed thus the
researcher recommends other researchers to utilize it in their studies. In addition consultants
in the IS healthcare research can benefit from these findings in their future endeavors in this
field. Majority of the IS consultants are more positivist oriented thus the findings of this
study should guide them to give equal attention to non-technological perspective. In essence
they need to give equal weight to the other three categories that emerged from this study.
6.6 Limitations of the Study
The findings of this study cannot be utilized generally in other service sectors because this
was more of a case study done in Kenya only so it may be hard to apply the results of this
study to explicate other happenings, of other countries not similar to Kenya. E-health
research in the IS society is generally new; little research has been conducted and published
in developing countries. Generally much of the available literature is skewed towards the
developed countries. Thus there is little literature review available for developing countries.
The study generated a theory that explains the issues that need to be addressed for e-health
implementation to be successful. However this substantive theory is yet to be developed into
a formal theory.
6.7 Suggestions for Further Study
The research intended to distinguish the components that impact the up take of e-health
implementation in developing countries particularly in Kenya. The review was data driven
and came up with a model that may influence implementation of e-health frameworks. A
repeat of the same study can be done in a different context to make the substantive theory a
formal theory. A similar study may be done using other methodologies for triangulation
such as survey etc.
241
The research findings provide means to give guidance to Kenya’s healthcare sector
specifically and other developing nations, which have attributes like Kenya regarding
population demography, particularly in the healthcare sector area. Hence, studies to contrast
the results of this examination in other developing countries might be of an incentive in this
unique situation. These relative studies ought to be with the nations similar to Kenya, in any
event in some fundamental attributes to permit the researcher to generalise the outcomes.
The findings of this study can be repeated in another context to find out whether the
outcome would be similar. A further study may be done to compare the model from other
developed countries versus the model developed in this study. In addition an extension of
the study can be done to establish the factors that affect actual usage of e-health systems in
Kenya.
6.8 Chapter Summary
This chapter gave a brief summary of the findings of the study together with
recommendations and conclusions. The implications made by the study are discussed in
detail as well as highlighting areas for further research. The main contribution to the body of
knowledge is the development of the new theory that is grounded from data. This adds on to
the already existing IS knowledge in the area of implementation of the systems. Further
studies may be done in other contexts to make the substantive theory a formal theory. In
addition further studies may be done using other methodologies commonly used in IS
research for triangulation purpose. Thus this study was distinct in its own way mainly by the
methodology adopted for the study. Grounded theory methodology resulted in theory
building which was a divergence from the common practise of theory testing. Hence this
provided the researcher with a deeper and more complete understanding on the
implementation of e-health in the healthcare sector.

242
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APPENDICES
APPENDIX 1: Interview Guide
What is your understanding of e-health?

What are the benefits of e-health to your citizens in general?
What do you perceive as the benefits of e-health to the economy as a whole?
What are some of the hurdles that you are facing with the current manual systems?
How would implementation of e-health systems be of assistance?
ICT Policy and e-health policies

What is your understanding of ICT policies?
What e-health policies are you familiar with?
Are there policies specifically tailored to promote the utilization of ICTs in healthcare?
Have you been involved in developing any of the healthcare policy?
How does the ICT policies affect e-health systems implementation?
Computer Security & Standards of e-health

What is your understanding of computer security?
What security controls would be necessary for the success of e-health implementation?
What standards are you familiar with?
What policies are specifically tailored to ensure data security and standards in healthcare?
How does computer security affect e-health implementation?
How do standards affect of e-health implementation?
ICT Infrastructure
What is the kind of IT infrastructure is available in your organization?
Are there more reliable and readily accessible ICT infrastructures in healthcare?
What is the quality of healthcare infrastructure available?
Does the government influence the supply and demand of ICTs in healthcare?
Does the government ensure standardization of interconnectivity, interoperability and
quality of information of computer networks?
What challenges do you have in regard to infrastructure in relation to healthcare support?
Does the government regulate the supply of ICTs infrastructure (for example: removing
economic barriers).
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Does the government regulate the demand of ICTs?
Does the government gives ownership and control of telecommunications provision to
private enterprises and private enterprises can freely compete in the mobile phone, ICT and
ISP markets?
How does the government promote the development of ICTs?
Is there adequate number of wireless networks available?
Is there a steady supply of electric power, whether by national grids or backup electrical
generators in the organization?
Do health institutions have adequate access to phone services, whether land telephone lines
or mobile/cellular phones?
How does the infrastructure affect e-health implementation?
What solutions would you recommend to these challenges?
Organizations and ICT competence

How does the organization generally support and actively promotes the structural change
when introducing e-health (strong leadership, invest in training and experiment with the e-
health technology, etc) and necessary.
How does top management support the e-health project by word and action?
Whose responsibility is it?
Is there adequate number of ICT workers skilled in developing and maintaining ICTs,
training others how to use ICTs, and managing ICT infrastructures?
Do top managers support the project by word and action?
Are Healthcare professionals, administrators, patients, and other stakeholders closely
involved in the design and development of the e-health systems?
Are Healthcare professionals computer literate and are adequately trained in using the
system?
Who is one person who purposefully champions the project by encouraging and advocating
it?
Is the system development team is skilled in the pertinent technologies.
Attitude and Behaviors related to e-health

Is there a greater readiness for e-health?
What are some of your experiences in e-health systems?
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Are the staffs well trained in use of ICT applications?
What are some of healthcare challenges and how can use of ICT help?
What are some of the barriers to implementation of e-health systems?
Health practitioners generally do not trust ICTs.
Health practitioners typically prefer to adopt ICTs only if they have been proven to be
effective.
Health practitioners are usually hesitant to attempt new ICTs applications.
How can we ensure e-health systems are successfully implemented in Kenya?
What are the main barriers to e-health implementation?
Suggest possible solutions to these challenges
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APPENDIX 1I: Samples of interviews scripts
Samples of interviews scripts from open and selective coding
“We are well aware that the quality of e-health services are not up to the level of the dream
of every kenyan , but innovativeness may make the dream come true” (C13).
“ I believe that the beginning should be by seeking for alternatives to existing policies to
provide Kenyans with better and improved healthcare services. However if the e-health
system were to be operational they need to be easily accessible and available at all times of
need” (C2).
“Also, service response time is important for us” (C1).
“Despite the presence of a few systems in the institution we are yet to experience a fully
functioning e-health system. The expectations would be that the systems would have be
interoperable and well structured. This would go a long way in the supporting data sharing
among institutions” (C8).
“Security is paramount when we talk about passing data over a network. Thus there is need
to have systems that protect the patient’s information so that confidentiality is maintained as
well as addressing issues of emerging security solutions. Furthermore backup mechanism
goes hand in hand with protection of the data” (C9).
Communication amongst various stakeholders is very key in enhancing decision making.
The systems need to be interactive to support this aspect” (C5).
“Meeting user requirements is key to any success of the system. Thus it should be
customised to suit the particular context of the organisations need. In most cases things are
done the way round and in this case the system would be bound to fail”(C6).
“The system should have its sufficient documentation to facilitate ease of use” (C15).
“There should be online support that assists users in solving problems when needed to do
so. This helps in technical support during use of the systems” (C7).
“we should not be discussing quality of the e-health systems first since these systems do not
exist in the first place as they exist in theory they but not in practise. Thus I feel that quality
may not be a key issue to implementation of the systems in this case” (C4).
“Iam not sure how quality of e-health systems would be related to its implementation
however the system needs to have user friendly interfaces for easy navigation” (C3).
“let me must admit there are budgetary constraints, the government is willing but not able.
The available funds are given to priority areas whereas e-health is considered a luxury than
a necessity” (C6).
“The government relies on donor funded projects in the sector. These donors are
conditional projects that are meant to serve the needs of mother countries. So most of these
donors funded systems are unwilling to integrate with the local systems to share data”
(C14).
“There is poor coordination from development partners which results to many fragmented
systems that exist that are meant to serve certain donor driven needs. Resources used to set
up these systems would be helpful if there was cooperation and coordination in the design
and implementation of these fragmented systems thereby reducing costs of
infrastructure”(C2).
“The government lacks leverage when dealing with development partners which leads to
fragmented system. Because of financial reliance on the donors the government is compelled
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to accept the donor conditions thus are reluctant to integrate their systems with the existing
systems” (C7).
“Most NGO’s’s are unwilling to work together or even share infrastructure resources and
funding because of the policies from mother countries” (C1).
“We hardly make too much than the need for basic needs” (C21).
“E-health may be regarded as a luxury not a basic need” (C21).
“The current healthcare is meeting my needs so I do not see why use technology” (C11).
“Most of the rural areas are not connected to electricity so using electronic gadgets might
be difficult” (C9).
“I agree the rural areas are worst hit when it comes to connectivity issues” (C9).
Internet connection is stronger in urban areas than rural areas “(C1).
“We rely on technically inadequate expertise for advise” (C3).
“I agree the team spearheading implementation are not technically qualified” (C9).
“The confusion lies on who is technically qualified to head implementation” (C14).
“We do not have qualified technical team to support the process” (C27).
“We rely on interns for provision of IT service and as such not qualified to support the
implementation” (C5).
“There are very few qualified IT officers in the organisation thus IT support is a real
problem” (C16).
“Its costly to hire qualified IT officers” (C29).
“Hoping that there is a commitment from the institutions not to use the data for other
purposes without prior permission” (C13).
“My experience with some government departments makes me afraid to be clear enough to
accept utilising the systems” (C4).
“there must be specific controls on what information can flow among departments or to
other institutions” (C6).
“Also we believe that a policy outlining how the patient data will be used and stored would
make me comfortable utilising the system” (C28).
“The healthcare facilities do not share data as there is no agreed standard for
interoperability” (C17).
“Interoperability is difficult to achieve because of lack of standards” (C2).
“There are no incentives offered for data exchange” (C10).
“We are unwilling to share the data” (C17).
“Incentives are lacking” (C28).
“What we have in general is many standards that do not address one area of technology
application” (C19).
“There are many existing some conflicting and overlapping as well” (C10
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APPENDIX III: Memos
Writing memos for categories emerging from the study

Box 5.1 memo 1
quality of e-health systems
There is an urgent need to improve healthcare services provided to all healthcare
institutions in the country. This can only be possible by harnessing ICT as a key
enabler the management of patients. This includes development of systems that the
healthcare stakeholders can interact with without problems. The system should be
operable and user friendly at the same time accessible, available and timely. However
the implementation of such systems in the healthcare sector is a tall order and
requires the involvement of every stakeholder in the process. The stakeholders have a
certain minimum expectations of the quality of the e-health systems that they would
meet their needs accordingly.
Box 5.2 memo 2

Social cultural environment
It is clear that social cultural issues have an effect on the implementation of e-health
frameworks. These incorporate Lack of goodwill, dread, depersonalized human services,
risk to patient security, potential device for impedance, unemployment rate, absence of e-
culture, manner to self-transaction and up close and personal correspondence, less measure
of open correspondence, resistance, sabotage, staff ignorance, corruption. however
overcoming these social cultural issues may build trust in utilisation of the system
Box 5.3 memo 3

Social economic environment
It is clear that social economic issues affect implementation of e-health systems. These
include: Socioeconomic environment Purchasing power, population growth, digital divide,
and distribution of resources, generation gap, poverty levels, literacy, demographic
characteristics, low income rate, sustainability, Equity and access. Settling these social
economic issues would increase the purchasing power of the citizens therefore utilisation of
the systems becomes more effective
Box 5.4 memo 4

Legal environment
It is clear that legal factors have an impact towards implementation of the e-health
frameworks. This include: Lack of a powerful legitimate condition for e-exchanges,
absence of e-laws for online exchanges, obsolete arrangement of enactments, laws
and directions in regards to online exchanges, absence of patient information
assurance laws, absence of implementation of the existing laws, penalty’s lacking,
liability. having an enabling legal environment will facilitate system integration and
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data sharing
Box 5.5 memo 5
Online safety and security
It is clear that online safety and security is a noteworthy concern with regards to e-
health. Clients are worried of the security of the information as it is transmitted over
the system. Different issues of security include: Privacy and security, framework
endorsement, security preparing, familiarity with Internet health, interruption
recognition, and attentiveness of individual data, framework review, recognizable
proof and validation, get to control, data security, chance appraisal, data
confirmation, internet security, good security procedures, management complacent.
unless these issues are sorted then users will remain adamant to use the systems
Box 5.6 memo 6

Organisational management and efficiency
It is clear that there are management issues that directly affect the implementation of
e-health systems. They include: Lack of senior management support, innovativeness
orientation, lack of liability within public, lack of public private partnership,
interdepartmental conflict, organisational bureaucracy, foreign donor projects,
bureaucracy in the supply chain, Strategic orientation of key stakeholders in the
project, unrealistic expectation ,Lack of clarity regarding specific costs, trust issues,
Conflict of interests, these issues need to be addressed for there to be successful
implementation
Box 5.7 memo 7

IS Capability
To enable use of e-health a country requires a good infrastructure. Other issues that
are related to IS Capability include: Interruption of Internet, cost of e-services,
inadequate capacity for information processing, inadequate ICT infrastructure,
technology, back up facilities, lack of standard, poor definition of users role, clients
have poor definition of specifications, lack of clear e-health policies in
implementation. These need to be addressed as they provide the platform on which e-
health is implemented
Box 5.8 memo 8

e-standards
It is clear that e- standards are a barrier to e-health implementation. Others related to e-
standards include: lack of available standards, no legislation exists; standards do not address
one unified area of technology. these to be addressed as well for the success of the project
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Box 5.9 memo 9
ICT competence
It is clear that ICT competence is a hindrance towards the success of e-health projects. These
include: inadequate ICT training among healthcare workers. There are inadequate numbers
of health laborers with the ability to configuration, convey and adequately oversee e-Health
frameworks. Moreover the utilization of ICT encouraged learning stays restricted in most
health preparing foundations. This is made worse by the inadequate IT personnel available
in the sector which is characterized by high turnover of the staff for greener pastures.
managers need to capacity build on their staff so that they can acquire the right IT skills to
use
Box 5.10 memo 10

Macro political factors
It is clear that micro political factors affect implementation of e-health systems. They
include: Poor history of IT implementation in the healthcare sector, social economic
imbalance, overseas donor investments, lack of collaboration between the private sector and
public sector, weak sustainability of funding, low political good will in sector, insufficient
knowledge about e-health, embedded corruption, ROI is lower in healthcare. These issues
need to be addressed as they touch basically on all other factors of implementation
Box 5.11 memo 11

System integration
It is clear that system integration is needed in order to share data among various facilities.
This include: poor coordination between national and county government hospitals ,
incompatibility, reengineering of internal structures, absence of standardisation to exchange
data, interoperability problems, lack of synchronisation between systems, lack of integration
of donor funded systems and local systems.
Box 5.12 memo 12

Change process management
It is clear that change process management is an important element toward
successful implementation of e-health systems. This include: committed for change,
mentality of workers towards tolerating change, change preparedness, absence of
champion to execute change, absence of association in change handle, assets for
change, imperviousness to change, non-appearance of promoters and supporters in
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the establishments to roll out the improvement, absence of progression arrangements,
absence of partners contribution in the plan and advancement of the framework,
complacent management, disconnect between policy and implementation, lack of IS
leadership champion. Various stakeholders need to be involved in the process so that
they do not sabotage the implementation. Resources need to be put aside for the
process as well.
Box 5.13 memo 13

Quality of health systems
It is clear that quality of e-health systems affect its implementation, as users are bound
to resist or use the systems depending on the quality of the systems. This include:
availability, accessibility, responsiveness, traceability, context -focused, well-defined,
interoperable, online support, user friendly, reliable, security, well-structured, and
interactivity.
Box 5.14 memo 14

Benefits of e-health systems
It is clear that the stakeholders appreciate the benefits that the health systems would
bring to their practice. These include: Accurate diagnoses, accessibility,
interoperability expert diagnosis, Increases timeliness of treatment, supports real-time
treatment, National planning for the population, Empowered citizens, Increased
productivity, efficiency and minimized costs, Governments becomes more responsive
to health needs, Equitable and accessible healthcare to all citizens. Thus everything
need to be done to ensure that the systems are successfully implemented so that the
users can utilize the technologies
Box 5.15 memo 15

Relationship between organisational and macro political factors
There is a relationship between the political environment and organisational efficiency.
Political goodwill results in better organisational leadership and management, which in turns
champions the implementation of the e-health systems. With good leadership the
organisation has a clear strategic direction of where it is going.
Box 5.16 memo 16

Relationship between online safety and legal factors
There is a clear relationship between online safety and legal factors. For the online to be
enforced on the network it needs to be backed up by laws and regulations that back it
265
Box 5.17 memo 17
Relationship between the economic and cultural factors
There is a clear relationship between social cultural factors and economic factors.
There is a major divide in the population in terms of access and literacy levels. The
more economically poor the users are, the more likely they are to resist introduction
of technology as this comes with a cost aspect.
Box 5.18 memo 18
Relationship between change process management and quality of systems

Many parts of the utilization of e-health frameworks depend for the most part on
dealing with the change procedure regarding support and communication.
Additionally preparing how the attributes of the systems user interface can be a
driver or hindrance to the clients using the innovation. This implies the
nonappearance of management practices towards implementation of e-health will
affect the quality of e-health frameworks.
Box 5.19 memo 19

Relationship between social cultural environment and organisational efficiency
There is a reasonable connection between social and organization effectiveness. This
implies confidence in an e-health framework that requires trust both in the
association, and additionally confidence in the innovation, where clients are
guaranteed that the frameworks can address their issues adequately. Accordingly it is
basic to re-assemble trust between the clients and the organization and this requires a
particular accentuation on a few perspectives that influence the clients of the
innovation.
Box 5.20 memo 20

Relationship between IS Capability and implementation of e-health
There is a relationship between the improvement of technological infrastructure on
the effectiveness of e-health. The stability in the infrastructure platform in terms of
consistency, accessibility, ease of use, affordability and maintenance is amongst the
main reasons that positively influence implementation of e-health in the country
today.
266
Box 5.21 memo 21
Relationship between legal environment, and system integration
It is clear that there is a relationship between legal environment and systems integration to
share data. Organisational culture requires a legislative and legal environment to ensure the
exchange of information between various health facilities. Thus, the absence of a legal
environment and legislation relating to the application of IT interoperability in the
healthcare sector causes a negative effect on the exchange and integration of information
systems across the various health facilities.
Box 5.22 memo 22

Relationship between political environment and organisational efficiency
There is an association between political decisions and attitudes on the implementation of e-

health. Political goodwill and enabling environment leads to effective leadership at
organisation level thus this positively affects the organisations implementation of e-health
systems. The political environment plays a key role in determining the social and economic
development for the improvement of the general population and in essence trying to reduce
the digital divide between the rural and the urban citizens.
Box 5.23 memo 23

Relationship between social cultural and system integration
The analysis revealed that there is a dual relationship between the sociocultural environment
and the system integration among facilities. Culture, for example, resists change.
Nonetheless the integration of various information systems affects user’s responsiveness to
utilisation of the e-health systems. Integration and sharing of data might be hindered by
user’s cultural barriers such as fear of security of data online.
Box 5.24 memo 24

Relationship between social cultural and organisational efficiency
The exploration showed there is clear link between social cultural environment
and organisational efficiency on the other hand towards implementation of e-
health. This implies confidence in e-health frameworks requires trust both in the
organization, and in addition confidence in the innovation, where clients are
guaranteed that the frameworks can address their issues successfully.
Subsequently there is need to re-fabricate trust between the clients and the
organization and this requires the organisation to concentrate on a few concerns
that influence the clients towards e-health innovations.
267
Box 5.26 memo 26
Relationship between social cultural and implementation
The examination revealed the effect of socio social values and practices on the
dispositions of clients towards usage of e-health frameworks. This impact in nature is
regularly negative in the way of life common in developing countries where
innovation is seen as an intruder to their daily work than an enabler and thus explains
the negative attitudes of the users towards implementation of e-health in Kenya.
Box 5.27 memo 27

Relationship between organisational politics and implementation.
There is a relationship between organisational politics and implementation of the system.
Poor leadership leads to poor decision making thus lack of failure to involve all stakeholders
in the process of implementation may lead to the failure of the project. Personal interests
override the organisations interest. Bureaucratic structures in the organisation exist as a
barrier to the success of the project too.
Box 5.28 memo 28

Relationship between social cultural factors and implementation of e-health
There is a relationship between social cultural factors and implementation of e-health
system. Users perception towards technology will determine whether the they will
resist or accept technology. Others include fear of unknown, attitude and
technophobia
Box 5.29 memo 29
Relationship among all the factors
All the 13 factors seem to be integrated and interlinked. For e-health implementation
to be considered successful in the healthcare sector, all the factors require to be
functional otherwise its bound to fail. These 13 factors can further be combined to
form five main themes namely: macro political, organisational efficiency,
technological, legal and social cultural factors
268
Box 5.30 memo 30
The final model consists of five main contextual factors namely: macro political,
organisational efficiency, IS Capability, legal and social cultural factors. Even if the
organisation has a good will to support the e-health project, it requires the
prerequisite laws in place to support online safety and system integration. These are
all aspects of a successful implementation of e-health systems.
269
APPENDIX IV: Grounded Theory Methodology
The researcher starts with data gathering by use of open headed interviews. Data is then
transcribed and translated. Memos are written. Memos are the written notes or records of
analysis related to the development of the theory. When using grounded theory, we begin
memo writing from the very start of our research. This is followed by analysis of the
interviews using open coding. Openness in the initial coding helps researchers to explore
and allow new ideas to emerge. During this however, the interviews are analyzed and coded
using the segments word by word and line by line. At the second phase of axial coding data
that has been broken up into separate codes is re-assembled. This will be used to investigate
conditions of situations described in the interview, their action and consequences Charmaz
(2006).Final phase is selective coding. According to Strauss and Corbin (1990), this phase
aims to explore more depth and focus on the focal core code by verifying the initial
concepts, properties and categories, which is believed to have an impact on the phenomenon
studied. In selective coding the researcher begins to code in relation to the core category.
This in turn means that theoretical memos become focused on aspects of the core category.
The theory gradually emerges from grounded data through the constant comparison method
with the literature reviewed earlier.

270
APPENDIX V: Letter of invitation for the interview
Description
This research assignment is being undertaken as part of the PHD course on developing a
Framework for E-Health Implementation in Healthcare Sector in Kenya: A grounded theory
approach.
The researcher would like to use your feedback to develop an e-health implementation
framework for healthcare sector in Kenya that will assist to enhance healthcare delivery.
Participation in this study is purely on voluntary basis. You may wish to pull out from this
participation at any time without penalty or judgment.
Incase of any queries or further clarification please contact the researcher on

carolboore@gmail.com. All comments and responses will be treated as anonymous and with
utmost confidentiality. Participants are however assured that no one outside the research
team shall have access to the information provided and no individual will be identified with
any of the responses.
Consent to participate
By signing below you are indicating that you have read and understood the information
about this project and are willing/not willing to participate in the project.
I agree to participate in the project

I do not agree to participate in the project
271

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A FRAMEWORK FOR E-HEALTH IMPLEMENTATION IN THE

HEALTH CARE SECTOR IN KENYA: A GROUNDED THEORY

A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE

REQUIREMENTS FOR THE AWARD OF DEGREE OF DOCTOR OF

PHILOSOPHY IN BUSINESS ADMINISTRATION, SCHOOL OF

BUSINESS, UNIVERSITY OF NAIROBI

Signature …………………………………… Date…………………………….

LIST OF TABLES .............................................................................................................xi

LIST OF FIGURES ...........................................................................................................xii

ABSTRACT ........................................................................................................................ xvi

CHAPTER ONE: INTRODUCTION ..............................................................................1

1.1 Background of the Study ................................................................................................ 1

1.1.1 Strategic Issues in E-health Implementation ......................................................... 3

1.1.2 Healthcare Sector in Kenya ...................................................................................6

1.2 Research Problem ...........................................................................................................10

1.3 Objective of the Study ....................................................................................................13

1.4 Value of the Study ..........................................................................................................13

1.5 Thesis Outline ................................................................................................................14

1.6 Chapter Summary ...........................................................................................................15

CHAPTER TWO: LITERATURE REVIEW .................................................................16

2.1 Introduction ....................................................................................................................16

2.2 Definitions of e-health ....................................................................................................16

2.2.1 Forms of e-health ..................................................................................................19

2.3 Issues in E-health Implementation .................................................................................21

2.3.1 ICT and Health Policies ........................................................................................ 21

2.3.2 E-legislation ..........................................................................................................23

2.3.4 E-Health Infrastructure .......................................................................................... 27

2.3.5 ICT Competence ...................................................................................................30

2.4 E-health Frameworks .....................................................................................................31

2.5 Theories of E-Health Implementation ............................................................................34

2.5.1 Technology Organization Environment Model (TOE) .........................................34

2.5.2 Actor Network Theory (ANT) ..............................................................................36

2.5.3 Grounded Theory (GT) ......................................................................................... 39

2.5.3.1 Differences between Glaserian Version and Straussian Version.............43

2.5.3.2 Criteria for Evaluating Quality of GT Research Process ......................... 45

2.6 Empirical Studies on Strategic E-Health Issues ............................................................. 47

2.6.1 Summary of Literature Review and Research Gaps .............................................49

2.7 Research Approach ........................................................................................................52

2.8 Chapter Summary ...........................................................................................................54

CHAPTER THREE: RESEARCH METHODOLOGY .................................................55

3.1 Introduction ....................................................................................................................55

3.2 Research Paradigm .........................................................................................................55

3.2.1 Positivist Paradigm ................................................................................................ 58

3.2.2 Interpretive Paradigm ............................................................................................ 58

3.2.3 Pragmatism Paradigm ........................................................................................... 59

3.2.4 Grounded Theory and Pragmatism .......................................................................61

3.3 Research Design .............................................................................................................65

3.3.1 Qualitative Approach ............................................................................................ 65

3.3.3 Grounded Theory Methodology ............................................................................68

3.4 Population and Sampling .............................................................................................. 71

3.5 Data Collection ...............................................................................................................73

3.6 Reliability ....................................................................................................................... 75

3.7 Validity ........................................................................................................................... 75

3.8 Data Analysis ................................................................................................................77

3.9 Ethical Considerations....................................................................................................79

3.10 Chapter Summary .........................................................................................................80

CHAPTER FOUR: DATA ANALYSIS AND INTERPRETATION ............................ 81

4.1 Introduction ....................................................................................................................81

4.2 The Data Analysis Process ............................................................................................. 81