Methodologies stem from a study’s ontological and epistemological commitments. Employing a qualitative methodology, a nominalist’s ontological stance is taken as the paper focuses on the realities of entities, generative mechanisms, structures and causal powers within the implementation process of HIS in resource-constrained environments. Epistemologically, the paper’s stance is that of rationalism which deal with human moral reasoning and social constructs [16, 25]. The paper adopts the critical realism paradigm as it addresses the ‘epistemic fallacy’ of both positivism and interpretivism. To this suggests that followers of the two paradigms tend to assume that what exists is what is observed and experienced. However, in critical realism the emphasis is on the understanding of the existing association between the real, the actual and the empirical (stratified ontology) in a social world. In the context of this paper this would mean looking beyond what is experienced during and after the implementation of healthcare information systems in healthcare settings. The paper argues that this kind of understanding allows for causal explanations by postulating that mechanisms, social structures and the interrelations in varied contexts may cause the events and experiences of issues under investigation [26, 27]. Central to critical realism, is its methodology that focuses on the generative mechanisms that cause events that may or may not be observable . In addition to this, [29:123] argues that at the premise of a critical realist methodology is the question “what causes events associated with the phenomenon to occur?” From the stratified ontology, it is in the real domain that generative mechanisms reside. [30:911] define generative mechanisms as “…causal structures that generate observable events”. This mechanisms exist independently of the observable events but capable of producing patterns of events.
In order to understand and explain generative mechanisms of context-based factors of HIS implementation in healthcare settings, the study adopts  ontological stance of a critical realist. The author bases the stance on two sets of assumptions, (i) that an independent reality exists that incorporates dimensions and domains and (ii) that of a three level stratified ontology comprising of the three domains of reality; empirical, actual and the real as illustrated in Figure 1. The researchers believe that the stratified ontology of critical realism is key in its methodology that provides a roadmap for explanations of issues under investigations to take place. According to , critical realists believe that human knowledge (in this case empirical findings) captures a very small part of the broader and deeper reality of the phenomenon under investigation. As such there is a need for researchers to look beyond just the empirical data and in doing so, the  posits that researchers tend to engage in explanations to causal analysis. This brings forth the concept of generative mechanisms which argues is an act where some process is held accountable for an observable event. For example in the case of this paper, poor quality of data, fragmentation of information, bottleneck of healthcare workflow are observable events within the healthcare system that are triggered as a result of certain processes.
Drawing on the stratified ontology and the concept of generative mechanism in critical realism the causal variability is HIS implementation and subsequence adequate use in healthcare facilities in resource-constrained environments is sought.
Critical realism methodology
In this section of the paper, the a description is provided on how a critical realist based methodology approach is applied to identify and characterise generative mechanisms and structures in the implementation activities of HIS in a healthcare setting. This mechanisms and structure trigger context-based factors that have implications in the infusion of HIS into healthcare work activities to facilitate healthcare service delivery process. To illustrate this, the paper adopts the  six stepwise framework for data analysis in a critical study. Based on the framework, the first step involves the description of the events in the phenomenon under investigation. The authors posit that the identified events become the objects of inquiry (ibid). In the context of this paper this step involved the description of the case and unit of analysis which is the implementation of HIS for public healthcare service delivery. The study describes the role of HIS in public healthcare service delivery in a resource-constrained environment, its purpose of implementation as well as use. These late on become the object of inquiry in this paper. In the second step of the  framework involves the identification of objects that characterise the phenomenon under investigation. The key objects for this study would include the actors (people), institution and system that form part of the social structure with causal powers. This involved the identification of key stakeholder in the healthcare service delivery system including healthcare practitioners, policy makers, and management.
The third step in the framework involves the interpretation of empirical data or otherwise known as the abduction process or theoretical redescription. For this, the paper employs Activity Analysis and Development (ActAD) model Figure 3 as a theoretical framework used for the abduction process. The paper is guided by the underlying principles of the ActAD model including that (i) the object-oriented activity system in this case healthcare service delivery process which is taken as the prime unit of analysis and is viewed in relation to the other network of activities such as implementation of HIS; (ii) the second guiding principle is the idea that an activity has multiple voices. Interpreted in this study as an activity have multiple actors involved performing various actions. In the context of this paper includes healthcare practitioners, policy makers, managers and leader at various levels of the healthcare system all carrying out various activities. The third (iii) principle used is of the view that an activity system is an historical activity events that form over a period of time which is found to be true in the case of this paper. Healthcare service delivery in many countries is littered with historical activities that evolve over a period of time. The fourth guiding principle is the vital role contradictions within an activity system have as a source of change and development. In the case of these paper contradictions is evident in cases where perceptions such as that of implementation of HIS enabling efficiency in the delivery process has brought change to the manner in which technology is implemented and used. The final (v) principle guiding the analysis in this paper is the possibility of transformation and reconceptualization of the identified objects and motives .
The rationale for employing these ActAD model principles is that they are similar to critical realism in being relatively open with respect to particular methods, providing an overarching frame and conceptual tools of inquiry- they provide exploratory guidance rather than strict rules. In the fourth step of  framework, involves the identification of generative mechanisms that may explain the cause of observable events. This step is otherwise also referred to as the retroduction process. The authors classify the step into two categories (i) the interplay of objects and (ii) looking for micro-macro mechanisms. The paper interrogates the interplay of HIS implementation activities and the subsequent use to facilitate healthcare service delivery.  posit that the micro-macro mechanisms offer explanations to emergent behaviour in the phenomenon under investigation, whilst the macro-micro mechanisms give explanations to how he whole enables or constrain the various parts of the observable events [36, 34] .Step five, presents the results of the retroduction process, the mechanisms are analysed, to find what mechanisms may explain the outcomes.  propose the forward chaining to understand the intentions or backward chaining to understand the results. For instance, in this paper, causes that may result in inadequate implementation and use are identified/determined, the study should therefore look for mechanisms that led to the outcomes. This step prepares for step six where a decision is made whether a mechanism are satisfactory.
The sub-sections that follows illustrates the application of the stepwise framework in search of the generative mechanisms that can explain why existing HIS implementation in public healthcare facilities in resource-constrained environments do not adequately facilitate healthcare service delivery. The first step is the case description.
The case and unit of analysis
The term constraint is used in this study to refer to those effects that limit healthcare service delivery in public healthcare institutions. Constraints in this paper was categorized into two types of limits; time and resource limitations. ‘Time-constraints’ in the context of this study would refers to the overall turnaround time of achieving healthcare service delivery outcomes, whilst ‘resource-constraints’ refer to more controllable elements, such as staffing, materials and access to needed equipment to carry out healthcare activities. The empirical case used is located in the OR Tambo Municipality in the Eastern Cape Province of South Africa. Historically this region has experienced challenges associated with service delivery and the healthcare sector is no different. Both the municipality and the healthcare facilities in this region bear characteristics such low skills of a resource constrained environment. This can be attributed to urban migration where skilled worker prefer to move to better opportunities. The facility is government funded and provide tertiary healthcare services to entire region. The selection criteria of the facilities was also based on the availability of health information systems such as the District health information system, patient records management system, and laboratory information system.
Sampling of Participant
Data was gathered from participants from the empirical case who were selected using purposive sampling technique to produce a sample that could plausibly be assumed to be representative of the case. To accomplish this, the researcher applied expert knowledge of the population to select in a non-random manner a sample of subjects that represents a cross-section of the population. The study’s criteria for selecting the sample consisted of senior hospital and clinic managers (as they oversee the healthcare service delivery process at the hospital); Technical support administrators (as they are offer technical support on implemented technologies); clinical and medical staff including nurses (as they are the users of these systems for clinical work to provide services); administrators and clerks (as they use the systems for administrative activities to support the clinical activities); Provincial ICT directors (representative from the department of health- as they oversee the adoption and implementation of various technology projects in public healthcare facilities within the province). A total of 21 interviews were carried out over the course of 6 weeks.
Ethical considerations are principles and regulations guiding the handling of research in specific contexts  To conduct any data collection, the researcher adhered to all the ethical procedures stipulated by Cape Peninsula University of Technology and Eastern Cape province of South Africa, the Eastern Cape Health Department. This also included seeking informed consent from the hospital and the participants.
For data analysis, Activity Analysis and Development (ActAD) framework is used as a backdrop to the conceptual exploration and as an analytical lens together with thematic and content analysis (for document analysis) technique. Thematic analysis is used to construct thematic understanding of the empirical data. The ActAD framework in Figure 3 is used as an operation tool to understand, analyse and explain goals, procedures, actions, interactions and relationships between actors, tools and the environment of healthcare service delivery system in public hospitals.
ActAD is based on Activity theory, which assumes that IS projects such HIS implementation are a collection of work activities . Work activity according the (ibid) is a view of social activity as widely accepted, rule-based, deliberate and collective work by various subjects. This is in pursuit of a common purpose. Subject in the work activity use tools to carry out action towards achieving an outcome (goal) . According to , the work activity can be complex, situation dependent, and subject to value conflict as a result of the various actors with different activities and the pursued purpose that is shared by others (community).
Drawing on the ActAD framework, the healthcare service delivery in this paper is considered a collection of activities that are carried out by different actors (healthcare practitioners) whose common pursed purpose (object) is shared by others (community). As result the healthcare service delivery as a work activity is described as a complex, highly mutable, situation-dependent, and subject to value conflicts . The framework suggests that the notion of the purpose (healthcare service delivery) does not occur without purpose, but is in pursuit of an identifiable outcome (improved healthcare service delivery). Whether the implementation process of HIS in public hospitals is associated to a specific care purpose, has an impact on whether the tool is utilized and how. This is a key point towards understanding the factors of HIS usage in that it could (together with other factors) explain some aspects of usage (or non-usage) to facilitate healthcare service delivery. The framework also indicates that the purpose in the work activity exists before and along the activity, it does have a time-frame that end with the transformation of the object into an outcome, or an alteration of the purpose to achieve a desired outcome, possibly due to contextual factors. A desired outcome is a function of a successful interplay between the object and the action as well as mediation process, where the purpose goes through a satisfactory transformation into an outcome. The activity, therefore never an ends in itself, but a goal-oriented process toward a realization of the outcome (health).