Activity Theory as an Analytical Tool: A Case Study of IS Development for an Anti-Retroviral Treatment Clinic in South Africa

MARIA ROSALI DE FREITAS AND ELAINE BYRNE Department of Informatics, University of Pretoria ________________________________________________________________________________________________
Abstract Information systems development uses many different approaches and methodologies, such as soft systems methodology, to assist in the process of development and in the design of more successful information systems. However, many of these methodologies define information systems narrowly and fail to adequately take the larger contextual work environment into account. Activity Theory is a tool, borrowed from the field of psychology and development work research, which facilitates a more holistic view to be adopted by information systems practitioners and developers. In this paper Activity Theory, or more precisely the Activity Analysis and Development (ActAD) model, is used as an analytical tool in the design and development of an information system for an anti-retroviral treatment (ART) clinic in South Africa. The usefulness of applying the ActAD model is shown in this case study which focused on the investigation and observation of the quality of data and its use for decision support in the ART clinic. In addressing the question Does Activity Theory assist in highlighting challenges faced by the ART clinic with their current IS and assist in representing what users require from an IS? we established the usefulness of the ActAD model in four areas. These included the identification of: the need for change; viewing information systems as part of the work activity; recognising the role of different stakeholders, and; the need for on-going support. We conclude that Activity Theory is a useful tool for information systems development and in particular the ActAD model is a tool which enables a more holistic approach to be taken in information systems development. Categories and Subject Descriptors: H.0 [Information Systems - General]; H5.2 [Information Interfaces and Presentation]: User Interfaces User-centered design; Evaluation/methodology; Theory and methods; General Terms: Design, Human Factors, Theory Additional Key Words and Phrases: Activity Theory, Information system development, Anti-Retroviral Treatment Clinic, HIV/AIDS, South Africa

________________________________________________________________________________________________ 1. INTRODUCTION

The South African (SA) government has an impressive constitution and legislative framework, which recognises the right of its citizens to proper health care (Govt. of South Africa, 1996). In SA approximately 80% of the population rely on state provided health care. Health workers in the public health sector provide not only services at the formal health facilities, but also for various outreach programmes to the community, for example, immunisation drives. The effective management and delivery of the diverse services requires regular reporting of routine and exceptional information and healthcare workers already spend a significant amount of time collecting, recording, storing and transmitting various forms of data. The potential of information and communication technologies, to enhance existing reporting systems is increasingly being recognised. In 2003, the SA government commenced an Anti-Retroviral Treatment (ART) programme in selected clinics throughout the country [Department of Health. South Africa, 2003]. Supporting patients attending these treatment centres places great pressure on the health staff not only because of insufficient human resources and time, but also due to severe emotional strain. Pressure escalates as the number of patients requesting ART is increasing daily. An effective information system (IS) is needed to manage this increase in patients. Furthermore, the medical statistical data or demographics that is being requested by government and non-governmental organisations (NGOs) are placing further strain on the staff. An appropriate Hospital Information System (HIS) offers an opportunity for improved services through the use of data on medical details and patients to produce quick and accurate clinical, demographic and medical statistical reports. The current HIS needed to be investigated in order to provide a HIS that would be able to better assist the health professionals with the quality of data, its use and the management of information for decision support [Lippeveld et al., 2000]. A functioning IS would contribute to the reduction of the workload of the staff at the ART centres and address some of the problems arising from lack of reliable information. One of the shortcomings of IS is that often, IS systems are not viewed as an integral part of day-to-day work activities of the organisation in which they are to function. In this case study Activity Theory and more particularly the ActAD model, was used to help highlight the work and communication activities for which the IS was needed. In this paper, the ActAD model was used to investigate the quality of data and to illustrate the importance of linking and aligning IS development and work practices. Our point of departure is that by looking at IS as integral to the work ________________________________________________________________________________________________
Author Addresses: M. R. De Freitas, Dept of Informatics, University of Pretoria, South Africa; rosali1@gmail.com E. Byrne, Dept of Informatics, University of Pretoria, South Africa; elaine.byrne@up.ac.za Permission to make digital or hard copies of all or part of this work for personal or classroom use is granted without fee provided that the copies are not made or distributed for profit or commercial advantage, that the copies bear this notice and the full citation on the first page. Copyrights for components of this work owned by others than SAICSIT or the ACM must be honoured. Abstracting with credit is permitted. To copy otherwise, to republish, to post on servers, or to redistribute to lists, requires prior specific permission and/or a fee. 2006 SAICSIT Proceedings of SAICSIT 2006, Pages 90 99

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processes it is easier to understand the main challenges stakeholders face and broadens the developers understanding of how the IS is part of the communication and work flow processes. This paper focuses on the initial steps towards the design and implementation of an IS for the ART clinic, with the main research question being: Does Activity Theory assist in highlighting challenges faced by the ART clinic with their current IS and assist in representing what users require from an IS? The research method used in this paper was an interpretive approach, using Action Research (AR), for identifying gaps and room for improvement in the current IS at the ART clinic. In order to commence the diagnostic phase of the AR process Activity Theory was used as an analytical lens to understand the case study, as well as Checklands soft systems methodology [Checkland, 1999]. To address the research question we briefly introduce Activity Theory and its use in the field of IS in the next section. In the following section we describe the ART clinic in a public hospital in an urban setting in South Africa. We use Activity Theory to highlight the key challenges faced in this setting and the clinics expectations from an IS. We conclude with a discussion on how Activity Theory can contribute to IS design and development. 2. ACTIVITY THEORY AND IS

Activity Theory was used in the nineteenth century in the psychology field [Bannon, 1997]. One psychology principle was the so-called principle of unity and inseparability of consciousness (i.e.: human mind) and activity. The meaning of this principle is that the mind originates and develops through the persons interaction with the physical environment. Sergey Rubinshtein (who created the idea of human action as a part of psychological analysis) and Lev Vygotsky (the father of cultural-historical psychology) went on, to further develop the principle. In the 1970s, one of Vygotskys students. Alexy Leontiev formed the conceptual framework Activity Theory based on these principles. This framework differentiated between individual action and collective activity and the intertwining of both, where individual work can only be understood in relation to the work activities they are engaged with [Vygotsky, 1978]. Engestrm in 1980s [1987] expanded Vygotskys model and explored the collective activity as a systematic entity. Engestrms Developmental Work Research has been used both as a method for both studying and for developing work. Activity Theory, in this context, can be defined as: ...a very general framework for understanding human activities that offers an alternative method to that of human information-processing as to how people learn and society evolves, from a materialistic perspective, based on the concept of human activity as the fundamental unit of analysis [Bannon, 1997]. In IS, Activity Theory has been applied in the analysis of work activity and as an integral part of the development of work processes. The potential of Activity Theory has been used as early as 1991 where the object of analysis was the activity taking place rather than the IS itself, with a focus on the individual activity as opposed to the collective activities. However Activity Theory has not been used as much as was expected in the 1990s [Korpela et al., 2004] though the Activity Analysis and Development (ActAD) model, which is based on Activity Theory, has been used by Korpela [2004] to focus on the emancipatory and development manner of IS. To date the ActAD model has been used in a number of different ways in IS by this Finnish group in what may be termed descriptive research. Some examples are: analysing IS development as an activity in Nigerian software companies; tracing the historical development of a 14years hospital software project in a Nigerian university and; as an analytical lens for lay people nurses and doctors in Nigeria to analyse their own healthcare activities and information needs [Korpela et al., 2000; 2002a, 20006; Mursu et al., 2003]. Korpela et al. [Korpela et al., 2000] and Mursu et al. [2003] claim that the contributions of ActAD are that it is more illustrative and so can be more easily interpreted by people not familiar with Activity Theory or the IS discipline. The presence of the main individual actors within the activity (the individual vs. collective aspect) is made explicit and their work activities are explored as means of coordination and communication. As such the means of networking are illustrated and the systemic nature of the activity is emphasised by including its overall mode of operation. Activity networks are emphasised and organisational boundaries are recognised. IS are viewed then as a tool to facilitate actions and to enable workers to do their job better. ActAD assists in viewing activities as networks of activities comprising a collective of individual actions. In summary, Activity Theory conceptualises work development as an essential part of IS development. The representation of work activities (as illustrated in Figure 1), and which is used in this paper, is based on the analysis of an activity by Mursu et al. [2003, adapted from Korpela et al., 2000]. Activity Theory was used to illustrate the work processes and to illustrate the role of the supporting IS at the ART clinic. This case study is now briefly outlined. 3. ART INFORMATION SYSTEM AN ACTION RESEARCH APPROACH

In 2005, the Department of Informatics at the University of Pretoria was requested by the clinical director of an ART clinic to assist with the improvement of their existing IS. This request was supported through an initial investigation of the current situation and the capturing of the articulated needs of the clinic personnel. This AR diagnostic stage will be

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Mode of operation, Relations with historical phases other activities, Collective actor: group, mediated by team, means of Contradictions community networking of practice Means of coordination and communication: division of work, Individual rules, etc. action Actors: subjects Means of work: mental, instruments, facilities, etc.

Work process:

Object

transforms Outcome into

Elements of a work activity

Figure. 1. Role Analysis of an activity, [Mursu et al., 2003, based on Korpela et al., 2000]

IS Developers

IS Users

IS Clients

GOVERMENT

ART CLINIC

HOSPITAL

UNIVERSITY

NGO 1

NGO 2

CLIENTS

Figure. 2. Role players in ART clinic [based on Korpela et al., 2002a]

built on in further research, which will be conducted by the Health IS research group at the Department of Informatics at the University of Pretoria. It is this diagnostic phase which is reported upon in this paper. 3.1 Research approach Quality of data and its use is of vital importance to management when making decisions. In our everyday lives the use of data is important in all we do. Data involves people, whether it requires them to intervene in the process of gathering it or using it to feed other sources, making it a social system. The need for a change to the current social system implied the adoption of an AR strategy. Action Research is primarily applicable for the understanding of change processes in social systems [Baskerville, 1999, p. 7] Soft systems methodology was used to develop a rich picture (refer Figure 3) as part of the diagnostic stage. How data is collected, used or not used, and the reasons for this needs to be understood and interpreted, not measured. The basic position of this research is interpretive and therefore, data collection methods such as participant observation, structured and semi-structured interviews, were used to assist with the understanding on how the IS is used and also to understand the reasons why it is not used. The value and performance of the current IS needed to be researched if a possible solution was to be found to assist the healthcare staff in addressing the IS difficulties they encounter. Checklands soft systems methodology was used to assist in explaining the IS holistically using a rich picture [Checkland, 1999]. Concepts from systems theory approaches were used to portray the complex socio-political environment of ART clinic as an open system and its interaction with the broader environment. The rich picture illustrates the problem situation in which the stakeholders find themselves and represents an understanding of the
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current system and how it works. This conceptualised view of the system depicts the activities and interactions between the different stakeholders and the IS. It also includes expressions of peoples opinions, perceptions and fears of the
Date 2005 April to Nov Organisation/Institution HISP/SA National Dept of Health MRC Italian Aid NGO1 NGO2 ART clinic Practitioners and writers on HIS Purpose of interview Health IS and South African HIS No of interviews 9

May to Nov

Understanding collaborative partner positions Understanding of situation at ART unit Data quality and HIS in general

Sept to Nov Oct TOTAL

9 2 25

Table. 1. Details of interviews conducted existing IS. The key role players in the ART clinic are illustrated in Figure 2. Various techniques were used to collect data to develop the rich picture illustrated in Figure 3. These included: Use of available information, common knowledge, published documents and literature study on health information. Physical observation of the current process to watch and record the processes in the current system. Structured, semi-structured, unstructured interviews with various stakeholders were held. Either face-to-face or by email (see details Table 1). After collaborating with various stakeholders and noting their concerns and viewpoints towards the current HIS the ActAD model was used to represent the existing IS and also, the desired IS. Based on the interviews conducted, observations of work flow processes a rich picture of the entire work processes of the ART clinic was developed and is now briefly described. 3.2 Description of case study processes This section describes the flow of data throughout the current work processes at the ART clinic, paying special attention to the quality and use of the data for decision support. The initial task was to observe the current situation at the ART clinic and understand the data capturing procedures in the administration and consultation process of new, follow-up patients and patients receiving anti-retroviral (ARV) treatment Currently at the ART clinic, the registration process of patients takes a long time at the main hospital administration section outside the physical premises of the ART clinic. When patients have registered they return to the ART clinic for tests before they see the doctor for a consultation and again wait in long queues. The current flow of the system does not follow a rigid process and has been changed many times to try to accommodate the communication, social problems and staff shortages faced. A lot of data capturing errors occur. For example, when capturing identity document (ID) numbers that should be 13 digits, the current system does not verify the validity of the ID and incorrect ID numbers appear in files. As seen in the rich picture (Figure 3) the ART clinic processes and supporting HIS are quite complex. The picture also illustrates the various points of view of the role players identified above in Figure 2. This complex picture illustrates the complexity of the situation and is now briefly explained. There are three types of patients: New patients (including referral patients), follow-up patients and patients receiving ARV treatment (process 1 in Figure 3). All new patients need to register at the main administration of the hospital (process 2 in Figure 3). The ART doctors would prefer that the registration and administration of HIV/AIDS patients take place at the ART clinic only. Certain rules, guidelines, policies and procedures need to be in place regarding administration such as requirement of a South African documented (or passport if a foreigner). Though according to new laws, people should receive ARV treatment free a fee is usually involved. The ART clinic has no network or computer-based HIS to link up to the hospital system and the ART clinic IS is primarily paper-based and partially an electronic system. Therefore, patient data is re-entered into the ART clinic after the registration has taken place at the hospital (process 3.1illustrates the entry in the paper-based system and 3.2 represents the entry into the excel spreadsheet in Figure 3). The following example describes the process for a new patient (being Patient A). Patient A enters the ART clinic (process 1 in Figure 3), and goes to the administration clerk. A sticker (sticker labelled new) with a number is given to patient A (process 2 in Figure 3) with a new file containing basic patient file forms. Patient A then proceeds to hospital outpatients for new patient registration, in a different building about five minutes walk from the ART clinic. After registration, which takes about two to three hours, Patient A goes back to the ART clinic (process 3.1a&b in Figure 3) and hands the file with the registration details in it to the administration clerk. The administration clerk then makes an appointment with the doctor for Patient A. Patient A receives an appointment card with details of their next appointment. The clerk writes up Patient As name as well as the patient file number in a book of appointments (manually), with the date of the appointment.
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Patient A returns to the ART clinic for a follow-up appointment. Again Patient A firstly meets the administration clerk, who has already prepared the patient file, the afternoon before their appointment, containing all the documentation needed. Patient A receives a sticker labelled follow-up with a number (this will be used to determine the order of precedence). Patient A is then sent for tests and observations (process 4 in Figure 3) with the nurses. After the nurses have explained ART (patient initiation) and performed all the requisite tests, such as, blood, weight, urine and blood pressure examinations the patient file is updated manually. The patient blood samples are then sent to the laboratory for testing. Once the blood test results have been sent back to the clinic they are sent to the doctor for analysing and the patient file is then updated. The clinical doctor analyses 100 to 200 blood tests on a daily basis. Patient A then proceeds to the doctors queue and waits. Patient A has to wait until attended by the doctor (process 5 in Figure 3). From here Patient A has a few options: Patient A goes to see the counsellors, the social worker and the dietician. Currently the dietician, counsellors and social worker are in a different ward in the hospital. The dietician also has a long waiting queue (process 7 in Figure 3). The first consultation with the dietician lasts about an hour. The dietician requires certain clinical information in the patient file written up by the doctor to perform her dietetic observations. There are also additional forms inserted into the patient file at this stage. Additional documentation required by law is completed and then submitted accordingly to the Gauteng Department of Health, such as the demographics form, containing statistical data on ARV patients that needs to be submitted. Patient A (before or after the consultation with the dietician) proceeds to the social worker (process 3 in Figure 3). Patient A has to go through a multidisciplinary patient discussion with one of the ten counsellors (process 8 in Figure 3) available, on voluntary counselling and testing (VCT). The patient also receives information of how ART is given and its side effects, etc. For patients receiving ART, pill counting also takes place at the counsellors as well, 14 days after first appointment and once a month thereafter. This is to ensure that the patient has been taking the medication correctly. The social worker works closely with and also manages the counsellors who as she puts it, are not always equipped or knowledgeable concerning the needs of patients and their backgrounds. The social worker usually sees patients on their first visit and sometimes on their follow-up. She also keeps her own patient files and also has her own documentation. Patient A then returns to the ART clinic administration, where they go to the administrator or the data capturer (depending on whoever is available) to find out when their next follow-up appointment is. The patient details are updated on an excel spreadsheet. Patient A then receives an appointment card with details of their next follow-up appointment (usually 14 days after first appointment). Patients receiving ART have an extra step added in the flow of work processes. After seeing the doctor for the follow-up appointment, the patient is directed towards the ART clinic pharmacy (process 6 in Figure 3) to collect the ARV treatment drugs. The patient file is updated and then sent to data capturer, to update the system. Line management is a process to ensure that patients are following the correct flow within the system. This is conducted by nurses, counsellors, data capturer, admin clerk or manager of the ART clinic, based on whoever is available to help at the time, indicating no segregation of duties. After process 5 where the dietician, social worker and counsellors also need to be seen management of patient flow thus becomes difficult to follow from this point. Additionally, complexities can occur when a patient has other illnesses besides HIV/AIDS and require further medication or treatment. This could imply transferrals to another department in the hospital (depending on the severity of the case or what the additional illness is) or the collection of additional prescribed medication from the hospital pharmacy (process 6 in Figure 3). 3.3 Existing Information System To support this workflow process the IS at the ART clinic comprises a paper-based system and a partial computer-based system comprising of an excel spreadsheet. The paper-based system consists of a patient file, which contains all the necessary health-related documents on the patients past and present health condition. These files are usually stored in a filing room, which have started to form a physical storage problem. The files also become difficult and heavy to carry from one place to another, when gradually more documents from various hospital and clinic departments are attached to them. When a health professional requires data for another clinical observation they need to scramble through the stapled pages in a file. This process becomes unwieldy, frustrating and time consuming, as pages and pages of records are attached the longer the patient remains in the care of the clinic. The partial computer-based system contains the data captured by the data capturer on excel spreadsheets originally designed at another ART clinic. These excel spreadsheets contain information on Adult ART, Adult non-ART, Paediatric ART and Paediatric non-ART. They also contain statistical summarised information on a weekly and monthly basis, which aid in filling out the demographic (and other papers) required by law through the Gauteng Provincial Government and the National Department of Health. At the time of investigation there was also a pilot project in place at the ART clinic. This involves a smart card / biometric system which is capable of tracking drug distribution of patients with relative confidentiality and security.
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9 9 HIV/AIDS Patient 1 Paper-based process Hospital 2 3.1a ARV Clinic Creating a file for new patient or adding details to follow-up patient Patient 3.1b Funding 3.1b Patient Nutrition provides provides 3.1 b Patient file 4 Patient file is updated and Social Worker: One appointed nurse for the clinic Counsellors / Nursing Staff on temporary basis from Hospital Patient file is updated and Blood sent for testing LA BS: Blood Tests 8 Patient file 4 Data Capturer: Reception Senior Admin Clerk: communication Electronic process Statistics / Demographics 9 3.2 9

NGO 2

Registration

National Department of Health Patient file

3.1b

8 Patient file is updated

Patient file

8 communication Ten Lay Counsellors

Pill counting

Patient Patient 7 Multi-disciplinary patient discussion 7 Patient file is updated and Dietician: blood results checked & sent data capturing Blood results are requested communication 5 6 Patient Patient file is updated and 6 ARV clinic Pharmacist 6 Patient file is updated and Patient file 6 Patient 6 Hospital Main P harmacy 6 Patient file is updated and Patient file

7 5 Consultation

Patient file

Medical Doctors from department of Family Medicine: and NGO1 Doctors: Paediatrics Doctor:

6 ARV medication Patient

6 Other medication

Figure. 3. Patient and Data Flow Chart

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Figure. 4. Current ART clinic system

4.

DISCUSSION

As can be seen from the above discussion the IS is interlinked with the work processes of the ART clinic. The ActAD model was used as an analytical tool to understand this inextricable linkage and assist in developing an IS which supports the work processes. 4.1 Activity Theory as an analytical tool There are many work activities taking place as shown in Figure 3. This section describes the particular processes connecting the nurses and the data capturer (given as process 4 and 3.2 respectively in Figure 3). Each work activity would need to be similarly and individually unpacked to get a complete picture of the information management processes of the clinic. The reason for the selection of this particular work activity is that this research noted that many problems of data quality involved work activities around the capturing of data. This is illustrated using the ActAD framework (as in Figure 5). The framework of the ActAD model (illustrated in Figure 1) was used to illustrate the current situation (represented in Figure 4) and similarly the expected overall outcome and goal of IS in another illustration (shown in Figure 5). The feasibility of implementing such a system is the subject of further investigation. Figure 4 illustrates the relationship between: Actors and subjects: the ART clinic staff who work together in the current system in order to produce healthcare for the HIV/AIDS patients requiring ART (point 3 in Figure 4); Means of works, the instruments and the facilities: the computer, excel spreadsheet, documents in patient files, statistical data and medical instruments (point 4 in Figure 4); Object: the unwieldy patient files (point 2 in Figure 4), and: Means of coordination and communication division of work, rules, etc: the communications via phone or verbally (such as shouting across a room to call a nurse to the phone), the rules stipulated and applied and use of captured data (point 5 in Figure 4). The researchers role was to observe the current situation by focusing on the object, the means of work, instruments and facilities and how the actors and subjects made use of the data collected. There are also external role players, illustrated by governmental (National Department of Health, playing a regulatory role) and non-governmental organisations (NGO1, establishing healthcare through research and development and NGO2, working in conjunction
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NGO 1

NGO 2

Figure. 5. Object and intended outcome of activities

with NGO1, used for a pilot project involving smart cards), that influence the ART clinic shown in Figure 4 as IS Developers. In order to create an ideal situation all entities must interact in a comprehensive manner, meaning that a proper system needs to be in place in order to automate the process. The actors and subjects remain the same (point 3 in Figures 4 and 5). The means of coordination and communication: division of work, rules, etc. (point 5 in Figures 4 and 5) would need to change slightly, meaning that a network infrastructure would need to be set up in order to put a HIS in place. Segregation of duties would also be required. The means of work, the instruments and the facilities (point 4 in Figures 4 and 5) would also differ slightly in the new system as the HIS would replace the excel spreadsheet. The ideal intended outcome of activities (point 1) as well as the Goals (depicted on the right in Figure 5) would be: A computer-based HIS that supports management functions and users in their needs as regards quality of data and thus its use for decision support A database where patient data and information can be stored and retrieved when requested timeously. A proper registration and administration support system that would be useful for appointment scheduling and other important tasks Electronic medical records kept as a clinical system More focus on patient healthcare 4.2 Usefulness of applying Activity Theory These representations of the existing work activities, using the ActAD model, in which the IS is situated and the desired IS highlight a number of challenges in changing the IS. These can be summarised as: The need for change Ultimately an improved HIS at the ART clinic would be very welcome. Currently, a computer network and connectivity is lacking and thus in future, a computer-based IS would be needed to facilitate the data capturing, analysis and reporting. However, as regards data quality, a good working manual patient administration process needs to be set in place before an automated process can be created. The current HIS does not support the management functions or work processes of the clinic. The information requested is not of a timeliness nature and no IS support to users, is provided by the current HIS.
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IS as part of the work activity The work processes need to be streamlined if a computerised IS can assist with improving data quality and help improve decision-making. Some of the improvements in the work processes would include: Segregation of duties: In principle there is segregation of duties of the staff at the clinic. In practice, due principally to shortages of staff, no actual segregation of duties was found. Due to the fact that ART clinic has shortages in human resources and workloads are high, co-workers help each other in completing their work tasks. However, this means that staff are performing duties for which they have not received any training or orientation. This causes a problem on many levels, such as breaching security issues regarding access to data and compromised quality of data due to data being entered incorrectly, incompletely or duplicated. Furthermore, there is nobody ensuring that each step of the administration process is followed systematically or correctly. No database currently exists and a lot of redundant, duplicated data surfaces between departments. For example, the dietician would require some or similar data that the medical doctor has. Verification of data: No verification or evaluation process of the quality of data captured in the IS, is in place. The use of a computer-based IS would help in limiting data capture errors (such as a system error or pop-up window when typing in the wrong number of fields in an identity number), but will not solve all the problems associated with poor quality data, such as errors carried through from source of data. Standardisation of ART clinic IS: A standardised tool is needed to integrate with other HISs and/or other health institutions or departments as well as with the new proposed IS which will be used. Standardisation ensures that specifications and procedures used for the designing and developing of an IS are created and adjusted to a specific norm in order to be aligned with additional information technology tools built by other establishments. This facilitates the exchange of information. Role of different stakeholders There are a wide number of stakeholders who need to use the data collected at the ART clinics. On a technical level, within the clinic, this would require ultimately an IS operating on a local area network. However, what appears to be the greatest challenge is the need for all the stakeholders to agree on a flexible IS that meets the minimum data requirements of the parties involved. Data is used differently on every level in the health sector. Stakeholders are more concerned in the IS according to their needs and wants. As a medical professional, the clinical aspects, data and observations are requested to be able to diagnose the patient and provide a better healthcare service. From a government perspective the statistical information regarding demographics is more important than the clinical information, for example, to be able to control the spread of illnesses in a country. From a management point of view, the costs-effective data is more relevant in managing the clinic and thus being able to provide more efficient healthcare services. The patient is interested in their well being and the healthcare services they receive. A collaborative process involving all stakeholders aligning their needs in relation to the HIS, would need to be addressed, but ultimately divergent needs for data cause difficulty in devising a system that will meet this competing needs. What may be more realistic is to find some common or minimum ground on which they will agree and have the flexibility within that system for stakeholders to customise it for their own needs. Need for on-going support Funding for information technology and training, as well as ongoing maintenance and support, will also be required once the system has been designed and implemented. The use of this IS within the ART clinic will only lead to improved quality of healthcare service if it is part of proper administration and resource management. Although this is also problematic this matter falls beyond the scope of the research, because an IS is a necessary, but not sufficient condition for improved administration and resource management, as well as an enhancement of data quality and use for decision-making. 5. CONCLUSION

The paper-based IS currently in place at the ART clinic does not meet the requirements of the administrative or clinical staff at the centres and does not support the effective and efficient delivery of services to ART patients. The paper explored this concern by looking at the work processes and where IS fits into those processes. Through the use of Activity Theory it is easier to understand what the main obstacles/challenges are to the stakeholders, but also broadens the developers/analyst understanding of how the IS is part of the communication and workflow processes in an organisation. In general Activity Theory can assist in a number of areas in IS design and development. The ActAD model used illustrates that work activities and IS are inseparable. An IS cannot be implemented successfully, as illustrated in the case study, if proper work processes are not in place. Activity Theory makes this quite explicit. Activity Theory also illustrates why IS are important in the work activities. Key stakeholders also need to be included as they impact the IS.
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Furthermore, Activity Theory helps focus the designers and users of an IS on what the main outcome of the work activity is and why IS can assist in this respect. 6. ACKNOWLEDGMENTS

Special thanks to all staff who participated in this research at the ART clinic. Many thanks to all the other people who agreed to be interviewed and who also commented on previous documents written on this research. Insights from health IS research group at the University of Pretoria were also appreciated. 7. BIBLIOGRAPHY
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