Chrisanthi Avgerou
email: c.avgerou@lse.ac.uk

Theoretical Framing of ICT4D Research

Keywords: ICT4D, theory of technology, contextual research, socio-economic development, middle range theory

Research on information and communication technologies for development (ICT4D) requires the combination of multiple theoretical strands. Central among them are the foundational theories on technology, on context, and on socio-economic development. In addition, ICT4D research draws from middle range theories, which shed light on specific topics of ICT related phenomena in the context of a developing world. In this paper, I explain what each of the three foundational theories is about and indicate the need for middle range theories. I suggest that the challenge for ICT4D research is to draw creatively from existing theoretical debates and to construct analytical routes and theoretical propositions suitable for the complex phenomena of ICT and development.

Introduction

Research on ICT in developing countries emerged in the 1980s, with studies of computer diffusion in various countries and studies of government policy about the use of computers in various sectors. [START_REF]Information Technology in Developing Cuntries[END_REF][START_REF] Odedra | Sub-Saharan Africa: a technological desert[END_REF][START_REF] Odedra-Straub | Global Information Technology and Socio-economic Development[END_REF]. Early researchers of what came to be known as 'ICT for development' (ICT4D) shared the belief that computers can solve many of the severe problems confronting developing economies and societies, such as grossly inefficient government administration, inadequate provision of health care and education and inability to compete in a global economy. There was a great deal of concern that computers were very expensive and governments in developing countries with pressing socio-economic needs used to tax them as luxuries. Since in the then global economy the competitive advantage of many developing countries was cheap labour, computerization did not seem a prudent policy. Many feared that automating factories and offices would deprive their economies of much needed jobs in industrial and service sectors. It seemed obvious, however, that computers could make a big difference in government number crunching, education and health. If only poor countries could acquire computers and engineering know-how to put them in effective use! In the 1990s, concern about the slow diffusion of computers was compounded with concern about limited telecommunications infrastructures, which severely restricted access to the internet. It was about that time that international development organizations (the World Bank, various UN agencies, ITU, national development aid organizations such as Canada's IDRC) and multiple NGOs started promoting ICT and access to the web. The discourse on the digital divide / digital inclusion has been anchored on the argument that ICT is necessary for development. Numerous publications of international development agencies produced tables correlating country development and internet accessibility indexes [START_REF]Human Development Report 2001[END_REF][START_REF] Kirkman | The Global Information Technology Report 2001-2002: Readiness for the Networked World[END_REF][START_REF] Porter | The Global Competitiveness Report 2001-2002[END_REF][START_REF]The Networking Revolution: Opportunities and Challenges for Developing Countries[END_REF][8], projecting a cause and effect relationship of ICT and development. At the top of the tables are countries that achieved high ICT diffusion with dynamic privatized telecommunication service providers; they are rich and have well educated and healthy population and democratic regimes. At the bottom of the tables are countries with pitifully little computing and telecommunication capacity; they are the poorest of the poor with low human development indicators and failed states. The causality between ICT diffusion and economic growth is supported with basic arguments about ICT and economic performance from neo-classical and institutional economic theories [START_REF] Avgerou | The link between ICT and economic growth in the discourse of development, in Organizational Information Systems in the Context of Globalization[END_REF]. Moreover, as good government, fundamental democratic principles of freedom, equality, liberal education and health assumes central importance in the debates of international development [START_REF]Human Development Report 2001[END_REF][START_REF]Human Development Report[END_REF], it is suggested that ICT is indispensable means for achieved such developmental objectives too.

Anecdotal evidence of transformative effects of ICT helped to popularise the causal claims about ICT and development. Women of a remote village on the Andes were selling handicrafts over the internet to American customers without ever having to leave their village or change their traditional lifestyle. Fishermen in Kerala started getting better prices for their catch as they received information on their mobiles about fish prices in the markets of different towns while they were still at sea. Indian villagers also filed requests and received government certificates in information telecentres without having to travel to towns and queue for hours in government offices. More than that, e-government software empowered them to keep government officials accountable by allowing them to file electronically grievances if they were not satisfied with government services.

Information systems on the implementation and use of computers and the internet in various types of organizations and in communities of developing countries, showed a more complex relationship of ICT and development. At close examination, even the popular anecdotes of transformational ICT uses were more complex than initially reported. The e-commerce activities of the women on the Andes village depended on the facilitatory business skills of a Dutch visitor to the village, who set up their web page for orders, sales and payments. Other women's cooperatives that set up an online presence for their handicrafts could not that easily succeed in selling to international markets [START_REF] Hassanin | Egyptian women artisans: ICTs are not the entry to modern markets, in Social Dimensions of Information and Communication Technology Policy[END_REF]. Keralite fishermen's optimal pricing on their catch had various other important conditions at play in addition to the use of mobiles [START_REF] Srinivasan | On the importance of price information to fishers and to economists: Revisiting mobile phone use among fishers in Kerala[END_REF]. And telecentres in Indian villages did not quite transform the relationship of Indian villagers with the Indian government [START_REF] Madon | E-governance for Development: a focus on rural India[END_REF]. Many of them struggled to be sustained and with time disappeared [START_REF] Madon | Digital Inclusion projects in developing countries: processes of institutionalisation[END_REF]. This is not to conclude that ICT diffusion has not been contributing developmental effects. In many developing countries, socio-economic conditions have been improving the last three decades, and big numbers of families are lifted out of extreme poverty, improving rates of literacy and control of diseases. ICT has been increasingly used in all sectors and all countries. Although not as ordinarily present as in the global North, computers, Internet connectivity and mobile phones are found almost everywhere and are visible in the practices of all development policies. It is reasonable to assume that ICT plays an enabling role in socio-economic improvements. Given that a simple cause and effect relationship between ICT diffusion and development outcomes is misleading because of hides other conditions at play, the challenge for ICT4D research is to understand and explain the complex processes of ICT-mediated socio-economic change.

For this, a lot can be learnt from the general theoretical debates on the relationship of ICT and organizational change in the Information Systems (IS) field. But we need to add theoretical capacity to address two salient aspects of ICT4D research: the developing countries context and socio-economic development [START_REF] Heeks | Theorizing ICT4D research[END_REF][START_REF] Walsham | Development informatics in a changing world: Reflections from ICTD2010/2012[END_REF][START_REF] Avgerou | Discourses on ICT and development[END_REF]. In this paper, I discuss the theoretical framing of ICT4D research as a combination of foundational theories on technology, context and development, with middle range theories, that is, theories of a less abstract nature, which are relevant for the specific research questions under investigation.

Theories of Technology

IS research has produced valuable insights on the relationship of IT and organizational change by focusing on the interaction of individuals with IT artefacts in the performance of organizational tasks. Seminal contributions to that end include Markus's [START_REF] Markus | Power, politics and MIS implementation[END_REF] explanation of resistance to change, Markus and Robey's [START_REF] Markus | Information technology and organizational change: Causal structure in theory and research[END_REF] essay on the causal structure of IT and organizational change, and Orlikowski and Iacono's [START_REF] Orlikowski | Desperately seeking the 'IT' in IT research -A call to theorizing the IT artifact[END_REF] theorization of the IT artefact. These contributions set foundations about the causal relationship between IT artefacts and social change,which avoid technology deterministic and social deterministic theses. The former locates causal agency solely at the properties of technology and leads to propositions of universal impact of specific technologies, irrespective of social context, while the latter locates causal agency at the social alone, positing that the material properties of technology do not matter as far as human societies are concerned [START_REF] Grint | The Machine at Work: Technology, Work and Organization[END_REF]. Rejecting both technology and social determinism as inadequate to explain IS phenomena, IS research developed perspectives that locate causality at the interaction of people with technology and consider IS phenomena as being formed by the engagement of individual actors with IT artefacts in their social context.

Several research streams have elaborated on the IT/human actor relationship as the fundamental causal explanation of IS phenomena. They include the sociotechnical systems approach [START_REF] Griffith | Beyond socio-technical systems: introduction to the special issue[END_REF][START_REF] Trist | Some social and psychological consequences of the longwall method of coal-getting[END_REF] and various approaches taken from the interdisciplinary field of Science and Technology Studies (STS) [START_REF] Bijker | Shaping Technology / Building Society[END_REF][START_REF] Law | A sociology of monsters: Essays on power, technology and domination[END_REF][START_REF] Howcroft | What we may learn from the social shaping of technology approach[END_REF] that articulate propositions about the way IS innovation happens. Particularly influential from among the STS theories has been actor network theory (ANT), which overcomes the lurking risk of social determinism by recognising technology itself as 'actor' and by seeing reality as formed by the actions of hybrid sociotechnical entities [START_REF] Monteiro | Actor-network theory and information infrastructure[END_REF][START_REF] Walsham | Actor-network theory and IS research: Current status and future prospects[END_REF][START_REF] Latour | Reassembling the Social: An Introduction to Actor-Network-Theory[END_REF][START_REF] Akrich | The de-scription of technical objects[END_REF]. More recently, the theorization of the relationship between IT and human action has focused on the notion of 'sociomateriality' [START_REF] Leonardi | Materiality and Organizing[END_REF][START_REF] Markus | A foundation for the study of IT effects: A new look at De-Sanctis and Pooles's concepts of structural featurs and spirit[END_REF][START_REF] Orlikowski | Sociomaterial practices: Exploring technology at work[END_REF][START_REF] Wagner | Understanding project survival in an ES Environment: A sociomaterial practice perspective[END_REF][START_REF] Zammuto | Information technology and the changing fabric of organization[END_REF][START_REF] Orlikowski | Sociomateriality: Challenging the separation of technology, work and organization[END_REF][START_REF] Leonardi | Theoretical foundations for the study of sociomateriality[END_REF]. A major stream of arguments in this debate reaffirms the idea that IS phenomena result from the dynamic relation of the material properties of IT with the socially derived ability of their human participants to act. It elaborates on the way IT artefacts and people interact to bring about IS phenomena, using concepts such as 'affordances' [START_REF] Markus | A foundation for the study of IT effects: A new look at De-Sanctis and Pooles's concepts of structural featurs and spirit[END_REF][START_REF] Zammuto | Information technology and the changing fabric of organization[END_REF][START_REF] Faraj | The materiality of technology: an affordance perspective[END_REF], 'imbrications' [START_REF] Leonardi | When flexible routines meet flexible technologies: Affordance, constraint, and the imbrication of human and material agencies[END_REF], or 'functions' [START_REF] Kallinikos | Form, function, and matter: Crossing the border of materiality[END_REF]. According to these views, both the IT artefact and the human actor possess causal capacity in the formation of IS phenomena. They are ontologically independent (i.e. one may disappear and the other may still exist) and epistemologically separable (i.e. each of them can be studied and understood without studying the other).

An alternative perspective takes its departure from an assumption of ontological primacy of actions rather than entities -whether artefacts of human beings. It considers IS phenomena as mutually re-configuring 'ensembles' of human and technology entities that are constantly producing/reproducing or changing each other [START_REF] Orlikowski | Sociomaterial practices: Exploring technology at work[END_REF][START_REF] Orlikowski | Sociomateriality: Challenging the separation of technology, work and organization[END_REF][START_REF] Pentland | Materiality: What are the consequences?[END_REF]. This view implies that IS phenomena should are constituted by a dynamic human and technology entanglement (intra-actions). Neither technologies nor people have an independent, self-contained existence and they are epistemologically inseparablethat is, impossible to understand by studying them as independent entities.

Both versions of sociomateriality theory focus on micro-settings of situated practice where intra-actions and interactions of IT artefacts and human beings occur. They both allude to broader contexts of IS phenomena [START_REF] Orlikowski | Sociomateriality: Challenging the separation of technology, work and organization[END_REF][START_REF] Faraj | The materiality of technology: an affordance perspective[END_REF][START_REF] Leonardi | Materiality, sociomateriality, and socio-technical systems: what do these terms mean? How are they different?[END_REF], but neither elaborates on the way contexts beyond situated practice are implicated in IS phenomena. Context remains elusive in the IS theories of sociomateriality and this limits their explanatory capacity in ICT4D research.

Contextualizing the Study of ICT

A distinguishing feature of ICT4D research is that it includes national, regional or community conditions and processes in the explanation of IS phenomena. But such contextual research is confronted with the question of what, out of the infinite number of conditions and processes amidst which IS phenomena are formed, needs to be accounted for [START_REF] Avgerou | Discourses on ICT and development[END_REF][START_REF] Hayes | Context and the processes of ICT for development[END_REF]. In other words, what is relevant context for ICT4D phenomena? I define context as the processes and conditions, other than the constituent causal sociomaterial interactions (or intra-actions) of IS phenomena, that affect their formation and are effected by them. In other words, context refers to conditions and processes in the environment of an observed IS phenomenon. For example, an information system of a doctor's surgery consultation involves the interaction of a knowledgeable actor (the doctor) and a complex set of software/hardware/telecommunications artefacts. A description of the doctor's interaction with the system's functionality provides a rudimentary explanation of the IT-mediated medical consultation, diagnosis and treatment decision. But we need to consider much more than the clinician/IT interaction to find answers to questions of interest in ICT4D research. For example, to understand whether and how a computerised clinician consultation system may help doctors to treat more effectively the population of a village, a city, or a country and improve population health outcomes or to explain why such systems may result in variation of health service delivery we may need to examine the organizational structures and processes of the wider health care system and the life conditions and health vulnerabilities of the population [START_REF] Findikoglu | Linking macro-level goals to micro-level routines: EHR-enabled transformation of primary care services[END_REF]. The theoreti-cal challenge for contextual research is to identify what else, beyond the constituent parts of an information system (i.e. the functionality of the technology, the behavioural characteristics of the doctor, and their interaction), needs to be taken into account to construct convincing explanation of IS phenomena and to assess their developmental impact.

Contextualization is the research design concerned with the identification of relevant context. It involves two decisions: (a) the choice of conditions and processes of the environment of a focal IS phenomenon to be studied by the research and (b) the choice of domains to be researched as the phenomenon's environment.

Identifying Relevant Contextual Conditions and Processes

ICT4D research has studied a large variety of contextual aspects related with culture, power structures, history, etc. Increasingly, these are not ad hoc findings of empirical studies but derived from middle range theories adopted to address specific research questions. For example, in our research of entrepreneurial opportunities created by the internet in developing countries [START_REF] Avgerou | Relational and institutional embeddedness of web enabled entrepreneurial networks: case studies of ntrepreneurs in China[END_REF], my co-author and I first agreed that, in order to understand why the diffusion of the internet is having a flurry of entrepreneurial effects in some regions in the world and almost no such effects in others, we should consider entrepreneurial activity as a socially embedded process. There are other ways to explain entrepreneurial activity, for example by studying the behavioural characteristics of the individual entrepreneur, but our interest was in understanding why individuals come to start doing business online is some regions and not others.

From preliminary research in China we understood that 'net-preneurs' in that country were clustered in some villages and towns and they all relied at the time of our research on the services of the giant IT services company Taobao. Existing knowledge couldn't explain why starting business on the Internet was clustered in communities.

We thought it a paradox that, while the Internet overcomes information asymmetries, shrinks physical distance, and enables business collaboration and economic exchange from any place, entrepreneurship was not occurring randomly but was clustered. We read a lot about clustering and entrepreneurship, IT innovation, competition and collaboration and e-commerce. We found that there had been research giving attention to social embeddedness of internet-based activities in IS research and organizational studies, mostly drawing from the importance of networked social relations [START_REF] Granovetter | Economic action and social structure: The problem of embeddedness[END_REF][START_REF] Schultze | A practice perspective on technology-mediated network relations: The use of internet-based self-serve technologies[END_REF][START_REF] Uzzi | Social structure and competition in interfirm networks: the paradox of embeddedness[END_REF][START_REF] Wasko | Why should I share? Examining social capital and knowledge contribution in electronic networks of practice[END_REF]. Relational embeddedness was therefore a promising theory to explain our puzzling observation of entrepreneurial clustering. But we thought that there were also other conditions enabling the formation of the Chinese clusters, which were not considered in the theories of relational embeddedness. We needed, for example, a conceptual language to address the role of the IT services provider, on whom the netpreneurs so heavily relied. We thought that the institutional structure of the Chinese economy had also something to do with the emergence of small-scale online new business ventures by large numbers of people without prior business experience. This led us to complement the relational embeddedness approach for the study of the conduct of online business with a version of institutional embeddedness proposed by the economic historian Karl Polanyi and his followers [START_REF] Polanyi | The economy as instituted process, in Trade and Markets in the Early Empires[END_REF]. These 'middle range' theo-ries of social embeddedness led us to construct an explanation of the emergence of entrepreneurial clusters in Chinese communities in terms of some specific institutional conditions of the Chinese political economy and IT services sector and aspects of culture in contemporary China.

Unlike the very abstract theories about the fundamental nature of social phenomena, such as the theories of technology I outlined in the previous section, middle range theories are relevant for specific topics [START_REF] Merton | On sociological theories of the middle range[END_REF]. The grounding of contextual explanation in middle range theory guides attention to contextual factors that may contribute to bringing about an observed phenomenon and the mechanisms through which they do so. It strengthens the ICT4D field by allowing us to trace the variation of research findings produced in different empirical studies [START_REF] Robey | Accounting for the contradictory organizational consequences of information technology: Theoretical directions and methodological implications[END_REF]. But the choice of middle range theory limits research attention to the constructs of the theories we use. In ICT4D research we tend to use theories from social science fields, most frequently organizational theory, behavioural or social psychology, sociology and economics. This has resulted in studies that consider only social aspects of context, as in the example of our research of Chinese net-preneurship. Notable for their rarity are explanations that account for material/technological aspects of the environment of ICT4D phenomena, including temporal and spatial characteristics and material life conditions. It is odd that most IS research adopts a sociomaterial perspective of IS phenomena but a purely social perspective of context. This is a weakness that I hope future ICT4D research will overcome by developing sociomaterial theoretical perspectives of the broader setting of IS phenomena.

Identifying Relevant Domains of Context

While in most IS research the assumed context of IS phenomena has been the organization in which ICT systems are implemented and used, ICT4D research tends to extend the research to domains of enquiry such as communities, countries, or global institutions. As I noted above, our research tends to consider context as a social domain, and we usually seek to unravel influences on the shaping of IS phenomena from social collectives that are assumed to be layered, typically organizations, regions, countries and the world at large. Our research design often involves cross-level or multi-level research strategies [START_REF] Braa | Developing health information systems in developing countries: the flexible standards strategy[END_REF][START_REF] Kambayashi | Cultural influences on IT use amongst factory managers: a UK-Japanese comparison[END_REF][START_REF] Nicholson | Some political and cultural issues in the globalisation of software development: case experience from Britain and India[END_REF]. The layered view of social collectives is underpinned by a systems theory perspective, according to which social collectives emerge from the interaction of their sub-systems and, subsequently, they influence the interactions among their constituent subsystems. A good example of this is research that adopted Pettigrew's 'contextualist' ideas [START_REF] Pettigrew | Contextualist research and the study of organisational change processes[END_REF] and studied IS development and impact as a process of change that unfolds through time under organizational and national influences [START_REF] Madon | Computer based information systems for development planning, in Social Implications of Computers in Developing Countries[END_REF][START_REF] Walsham | Interpreting Information Systems in Organizations[END_REF]. [START_REF] Walsham | Interpreting Information Systems in Organizations[END_REF] case studies of IS development explained key decisions and actions of IS development with reference to the changing culture and politics of the organization, both linked to national socio-economic and political changes. Similarly, Madon's (1992) case study of the introduction of computer based information systems in local administration offices in India explained their limited impact by showing how officers made sense of and used that innovation in the context of the layered Indian administration as well as the broader culture and social stratification of India.

The layered contextualization approach is compatible with and can be supported by middle range theories in established social sciences, such as political economy and sociology. But it has been criticised for reifying conventional notions of social structures. An alternative approach is achieved by tracing relations of the constituent parts of an IS phenomenon with other artefacts, individuals, and social groups contributing to its formation [START_REF] Hayes | Context and the processes of ICT for development[END_REF][START_REF] Faik | Modernisation through ICTs: towards a network ontology of technological change[END_REF]. In such relational approaches the study of IS phenomena may include influences from generally recognizable categories of social collectives, such as organizations and national states, but not necessarily in a layered order. Without levels of analysis that associate a phenomenon with enduring social structures, this relational contextualization approach is open ended and the identification of contextual entities that create conditions of possibility of a phenomenon is a matter of empirical investigation in specific cases. The tracing of relevant context by examining relations of the constituent entities and processes of a focal phenomenon with a more extended range of entities or processes is a research design with the potential to develop powerful new explanatory theory.

Drawing from Theories of Socio-economic Development

Socio-economic development is a multidisciplinary academic field in its own right. What do we seek to gain from its theories and how can we find our way in this complex area of academic research and policy practice? So far, ICT4D research has derived from development theories mostly definitions of desirable ends that ICT innovation should aspire to serve and to a lesser extent an understanding of the processes for achieving them. Two means/ends relationships between ICT and development are discernible in ICT4D research. The first adopts the notion of development as economic growth [START_REF] Mann | Information technologies and international development: conceptual clarity in the search for commonality and diversity[END_REF] underpinned by the assumption of neo-classical economics that technology increases productivity in organizations and, in an aggregate form, the economy at large. It thus gives rise to the projections the cause and effects projections of ICT impact in developing countries that I mentioned in the introduction. In its crudest -yet widespreadform, the economic growth approach to development associates measures of the diffusion of computers, internet connections or mobile phones with increases of Gross Domestic Product (GDP) and employment. For example, the 2015 Human Development Report, quotes a study which estimates that 'if Internet access in developing countries were the same as in developed countries, an estimated $2.2 trillion in GDP and more than 140 million new jobs -44 million of them in Africa and 65 million in India -could be generated' [62, p 89]. Similarly, Chavoula [START_REF] Chavula | Telecommunications development and economic growth in Africa[END_REF] derives the following estimate from an econometric analysis: 'on average, a 1% increase in mobile telephony users for every 100 people would increase per capita GDP by 0.39%, 0.26% and 0.15% for the upper-middle-, low-middle-and low-income countries, respectively'.

IS research has elaborated nuanced variants of ICT and economic performance, according to which productivity and economic growth are not just accrued from invest-ment in ICTs but require management and policy interventions for organizational and institutional change [START_REF] Brynjolfsson | Beyond computation: Information technology, organizational transformation and business performance[END_REF][START_REF] Dedrick | Information technology and economic performance: a critical review of the empirical evidence[END_REF]. Socio-economic analyses of ICT and economic growth have aso drawn from alternative economic approaches, which shift attention to other indicators of economic change, such as transaction costs [START_REF] Jensen | The digital provide: Information (technology), market performance, and welfare in the south Indian fisheries sector[END_REF] and competitiveness [START_REF] Porter | The Global Competitiveness Report 2001-2002[END_REF], and emphasise the importance of social institutions [67, chapter 17]. In promoting ICT diffusion, international development agencies too explain that the way ICT innovation contributes to economic performance of organizations, sectors and countries is multifaceted and marred with uncertainty [START_REF] Kirkman | The Global Information Technology Report 2001-2002: Readiness for the Networked World[END_REF]. In short, economic developmental outcomes do not result from the diffusion of ICT alone, and policy makers have to muddle through models that associate economic growth benefits of ICT with government interventions for regulation, structural reforms, education and social welfare [68]. This is clearly an area where ICT4D research can make important contributions. We should endeavour to answer the question: what does it take for ICT innovation to contribute to economic effects such as business creation, employment, elimination of poverty, government revenue generation to fund social services programmes?

The second perspective of development that has been influential in ICT4D research, centres on the notion of 'human development', which underpins the UNDP's Human Development reports, and the UN's initiatives known as Millennium Development Goals and Agenda for Sustainable Development (Millenium Project 2006; United Nations Development Programme (UNDP) 2016). The notion of human development draws from Amartya Sen's ideas of development as people's freedom to 'lead lives that they value', known also as the 'capabilities approach' [START_REF] Sen | Development as freedom[END_REF]. Key concepts in Sen's theory are wellbeing, which refers to a person's 'functionings' (what he/she can do or be) and agency, defined in this theory as the pursuance of what a person values or regards as important. Policies aiming to enhance human development adopt indicators for health, education, work, and political freedom. Income indicators are also included but they are understood as means for enlarging people's choices rather than as an end condition of development.

Sen's contribution to the critique of development as economic growth created awareness that development goals involve a moral choice. His capabilities theory has become the espoused theory of development for many ICT4D researchers. It serves as a normative intellectual device, from which ICT4D research derives objectives of ICT innovation. For example, from the perspective of the capabilities theory, conventional topics of IS research, such as entrepreneurial ICT activities or e-government, are examined for their potential and actual empowering effects for disadvantaged citizen groups (Jimenez and Zheng 2016; Madon 2005). More importantly, by invoking the capabilities approach, ICT for development researchers have broadened the research agenda of the field to study questions that rarely feature in IS research, but are crucial for human development, such as addressing gender inequalities [START_REF] Buskens | Agency and reflexivity in ICT4D research: Questioning women's options, poverty, and human development[END_REF] and education gaps [START_REF] Bass | A framework using institutional analysis and the capability approach in ICT4D[END_REF].

In addition to defining development goals, ICT4D research can draw from the debates on socio-economic development valuable lessons about the nature of the processes of action for the realization of development goals. For example, the operationalization of development theory in policy action involves conflicts of interests and strategies for domination at the local and global level. A thought provoking study that considers multiple aspects of the political economy of ICT-driven development is Carmody's [START_REF] Carmody | The informationalization of poverty in Africa? Mobile phones and economic structure[END_REF] critical study of the developmental role of mobile phones in Africa.

It is important to engage that the field of ICT4D research engages with the debate on the definition of the general notion of 'development' and the processes it entails. But I would argue that the theoretical challenge of ICT4D regarding development is not the choice between economic growth or human development approaches, but the grounding of our research on theories that problematise desirable socio-economic objectives with adequate specificity for the domains of ICT-enabled activities we study. For example, recently in my research I needed theoretical bearings to assess the contribution of ICT to the conduct of elections in Brazil and India, the formation of entrepreneurial activity in Chinese communities, or government administration reform in various countries. For each of these research areas I deduced developmental goals from theories that elaborated on desirable change, relevant contestations, and required enablers and impediments that are likely to frustrate the developmental contribution of ICT innovation.

I therefore suggest that the engagement of ICT4D research with socio-economic development discourse is not confined in the debates on the general definitions and approaches to 'development'. It is dispersed in a much broader theoretical literature that addresses transformative options in a range of domains of human activity. Again, such theoretical choice comprises middle range theories that conceptually describe problem situations and puzzling conditions of human institutions and offer models and analyses that help us identify the potential transformative role of ICTs.

Putting Together Multiple Theories in the Framing of Empirical ICT4D Research

The craftmanship of ICT4D research involves the framing of each of our studies theoretically by combining multiple theories. In this essay, I suggested three foundational theoretical perspectives that underpin all ICT4D research: ways of thinking about ICT and organizational or socio-economic change, ways of identifying relevant context, ways of thinking about transformations that make a positive difference in people's life conditions. These are present in all ICT4D research, but they are not always made explicit or argued about. In addition, ICT4D research involves assumptions, conceptual vocabularies and mechanisms of change that are specific to a topic under study -that is, middle range theories. A comparison of two PhD studies in my university can exemplify the theoretical framing I suggest for ICT4D research. Both studies concern the implementation of consecutive ICT systems for international trade management: one in Mexico, by Carla Bonina 1 , the other in Ghana , by Atta Addo 2 . They both adopted a sociotechnical perspective of ICT, assuming a recursive dynamic relationship between ICT and organizational change, according to which IT is implemented to bring about organiza-tional arrangements deemed desirable by some stakeholders, but is likely to be contested by others. Neither Bonina's nor Addo's research takes an explicit position regarding the definition of development -economic growth or human development. They both engage with specific questions about desirable transformation of public administration in relation to the development discourses in the countries they study and international influences.

In Bonina's study, the focal potential transformation is the mix of 'public values' at the core of public administration. She examines whether ICT implementation amidst organizational reforms triggered by policies of economic liberalization altered core values of public bureaucracies, such as fair service by following the rule of law. She complements the theoretical analysis of public values with a theory on discourse (critical discourse analysis) to trace ideological influences that shaped the orientation if ICT implementation towards supporting specific public value combinations. In Addo's study, the focal transformation is the 'modernization' of public sector services, that is, the reduction of red tape that has historically been formed in Ghana's patrimonial tradition of government administration. He develops an analytical basis by combining a typology of government administration historically formed in developing countries with the institutional logics theory of organizational sociology [START_REF] Thornton | The Institutional Logics Perspective: A New Approach to Culture, Structure, and Process[END_REF]. Bonina's contextualization approach spans two layers of context. Her analysis associates ICT implementation and its effects on the values underpinning practice in international trade administration with Mexico's political economy -specifically the policies of successive governments for opening up the economy and pursuing economic development through strengthening the competitiveness of Mexican firms. Addo's contextual analysis associates the situated practice of civil servants with organizational reform interventions of the public sector. It is thus contained at the level of the inter-organizational domain of Ghana's public administration.

I hope the two examples show the kind of combinations of foundational and middle range theories required in ICT4D research. Both these studies address questions about the developmental effects of the same techno/organizational innovation -ICT platforms for the administration of international trade -and contribute insights on the way ICTs come to make a difference in the public sector of developing countries. They adopt the same foundational theory of technology, but they contextualise their research differently. Importantly, they both draw also from middle range theories -on public values, institutional logics, critical discourse analysis, ideal types of administration. A clear theoretical framing is necessary for the articulation of research questions in conceptual terms, for the construction of an analytical route for an empirical study, and for delineating the theoretical contribution of the research as propositions that extend or refute existing knowledge on ICT4D phenomena.

Conclusions

My argument in this paper is that ICT4D research requires the combination of two types of theories: foundational and middle range. Foundational theories are very general and highly abstract -they tend to elaborate on the nature of social phenomena and processes through which they are formed. Invariably, ICT4D research requires theories about technology, about context, and about development. Middle range theories are more limited in their abstraction and relevance and their aim is to explain specific sets of phenomena.

Students often asked me what theory they should use for the research of so-and-so a topic. This is an impossible question to answer: it is not one theory that is needed in ICT4D research, but many; and nobody can prescribe the theories for the study of a topic. Research framing is the informed choice of theories in relation to which research questions are expressed and contributions to knowledge are made, and it is the most challenging part of academic ICT4D research.

http://etheses.lse.ac.uk/584/1/Bonina_public_values_information_2012.pdf

forthcoming


Yan Li
email: 1yan.li@cgu.edu

Manoj A Thomas
email: mthomas@vcu.edu

Sarbartha Sjb
email: ranasarbartha@gmail.com

Debra Stoner

Continuing Medical Education on a Stick: Nepal as a Test Bed

Keywords: ICT4D, Nepal, Continuing Medical Education, Citizen-centric Capacity Building Framework, CMES

The imbalance of health workforce between rural and urban has the most severe impact in low-income countries (LICs). One of the key elements in this disparity is the lack of professional development opportunities, such as Continuing Medical Education (CME), for rural medical practitioners. There exist few useful tools to effectively bridge the paucity of resources and access to CME for rural health care workers. Focusing on Nepal as a test-bed, we build, deploy, and evaluate an ICT-based platform called CMES (CME on a Stick), for the delivery and sharing of affordable and high-quality CME content for rural medical practitioners. We also refine the Citizen-centric Capacity Development (CCD) framework for ICT4D (Information and Communication Technology for Development). The CCD framework guided the development and evaluation of the CMES platform. The research contributes not only to the theoretical knowledge of linking ICT design and achievement of development goals, but also the practical knowledge of building ICT-based CME capacity for rural areas in LICs.

Introduction

The world is steadily growing more urban than rural, yet the gulf between the quality and availability of medical care between the two remains wide. A major contributor is the difficulty in recruiting and retaining rural health workers. While the imbalance of health workforce is common to almost all countries, it has the most severe impact in low-income countries (LICs) [START_REF] Chen | Human resources for health: overcoming the crisis[END_REF]. For example, the urban to rural disparity of practicing physicians per capita in Nepal has been estimated at more than 40 to 1 [START_REF] Butterworth | Retention of general practitioners in rural Nepal: A qualitative study[END_REF]. There is no one single explanation towards this disparity, but one key element is the isolation and lack of professional development opportunities, such as Continuing Medical Education (CME) for rural physicians. CME is defined as educational activities that serve to maintain, develop, or increase the knowledge, skills, and performance of medical practitioners in the medical field [3]. The ultimate goal of CME is to improve the health of individuals through services provided by the medical practitioners. CME is not only essential to improve physician performance and patient health outcomes, but also critical to maintaining a sense of professional pride, distinction, and identity [START_REF] Cervero | Effectiveness of continuing medical education: Updated synthesis of systematic reviews[END_REF]. Studies have shown effectiveness of CME in areas such as the acquisition and retention of medical knowledge, improving attitudes, skills, physician behaviors and clinical outcomes [START_REF] Marinopoulos | Effectiveness of continuing medical education[END_REF]. However, CME represents an overwhelming challenge in rural areas of LICs due to the complexity of socioeconomic and infrastructural problems, including limited access to context-relevant CME content from conferences, textbooks, journals and the internet, lack of mandated CME standards, as well as financial and technical challenges. There exist few useful tools to effectively bridge the paucity of resources and access to CME, and little knowledge about how CME might be used to improve rural medical care and population health.

This research serves two objectives. First, we build, deploy, and evaluate an ICT4D (Information and Communication Technology for Development) solution called CMES (CME on a Stick) for the delivery and sharing of affordable and highquality CME content for rural medical practitioners, focusing on Nepal as a test-bed. We believe that a free and open platform for CME knowledge sharing and distribution in LICs can catalyze significant reductions in urban-rural health disparities. It is important to note that ICT solutions such as Internet-in-a-Box and Raspberry Pi have been used to deliver educational contents to offline communities. However, none addresses the unique characteristics of effective CME in LICs, such as providing interactive and multi-modal methods of learning, gaining administrative support, offering incentives for practice change, and conducting needs assessment of health professionals.

Second, in the process of building CME capacity among rural medical practitioners, we continue the application and refinement of the Citizen-centric Capacity Development (CCD) framework for ICT4D [START_REF] Thomas | A Citizen-centric framework for ICTE Capacity Development in Haiti[END_REF]. As an inter-disciplinary research domain, ICT4D integrates computer science, information systems, and development studies [START_REF] Unwin | ICT4D : information and communication technology for development[END_REF]. While ICT includes the full range of computer hardware, software, and telecommunication facilities, ICT4D research is envisioned as an enabling tool with the capability to improve quality of life, empowerment, and economic development for the communities where it is introduced. Despite the huge investment from government, non-government organizations and private sectors in ICT4D projects, the impact of ICT in LICs remains minimal [START_REF] Thapa | Exploring the link between ICT and development in the context of developing countries: a literature review[END_REF]. The struggle of linking ICT deployment and achievement of development goals is usually a result of focusing more on technology and neglecting the complex social, economic, and political factors in LICs [START_REF] Brown | Highlighting the duality of the ICT and development research agenda[END_REF]. Although literature calls for exploring a broader context for ICT4D project [START_REF] Thapa | Exploring the link between ICT and development in the context of developing countries: a literature review[END_REF][START_REF] Njihia | The Broader Context for ICT4D Projects: A Morphogenetic Analysis[END_REF], existing research in ICT4D mostly focuses on either technical solutions or impact evaluation. Because the broader development context often influences the design choices of the ICT solution within which it is set [START_REF] Prakash | Importance of development context in ICT4D projects: A study of computerization of land records in India[END_REF], we believe that it should be considered throughout the ICT solution design process rather than explored in isolation. The purpose of CCD framework is to assist the design, implementation, and evaluation of ICT4D project with the consideration of the unique and complex context for development in resource constrained communities (e.g. LICs, rural communities).

The rest of the paper is organized as follows. First, we review CME challenges in LICs section 2, followed by a description of proposed CCD framework and project background in section 3 and 4. Section 5 discusses the CMES design process for CME capacity development, and section 6 concludes the paper by examining long term project goals and future research directions.

CME and its challenges ln LICs

The instructional design of CME activities draws insights from different academic disciplines such as adult learning, practice-based learning, continuing professional education, organizational change, development and behavior, and health services research [START_REF] Bennett | Continuing medical education: a new vision of the professional development of physicians[END_REF]. Most of the CME methods and activities are based on theories on adult learning, such as lifelong learning, theories of motivation, self-directed learning, reflection, and adult learning [START_REF] Merriam | Learning in adulthood: A comprehensive guide[END_REF]. Different CME methods include conferences and workshops, printed or recorded materials, mentoring and opinion leaders, clinical practice guidelines, interactive education, case-based training, audit and peer group discussions, educational outreach visits, reminders, and online education [START_REF] Marinopoulos | Effectiveness of continuing medical education[END_REF][START_REF] Bloom | Effects of continuing medical education on improving physician clinical care and patient health: a review of systematic reviews[END_REF]. Among these, attending conferences and reading printed materials are CME activities most commonly undertaken by medical practitioners. While CME is identified as a key element for maintaining good quality clinical care and a priority for health care providers in many countries [START_REF] Peck | Continuing medical education and continuing professional development: international comparisons[END_REF], the effectiveness of CME remains debatable. A recent synthesis of systematic reviews [START_REF] Cervero | Effectiveness of continuing medical education: Updated synthesis of systematic reviews[END_REF] on CME effectiveness concluded positive impact on physician performance and patient health outcomes. In addition, literature identifies key attributes of successful CME: (1) use multiple media and methods of learning; (2) provide adequate time to digest and incorporate knowledge; (3) incorporate needs assessments to ensure that the activity is controlled by and meets the needs of health professionals; (4) be interactive; (5) administrative support, and (6) provide policy incentives for practice change [START_REF] Cervero | Effectiveness of continuing medical education: Updated synthesis of systematic reviews[END_REF][START_REF]Redesigning continuing education in the health professions[END_REF]. In our solution design, we take into consideration the first four attributes, while fully aware that attributes five and six represent social and political aspects of CME and may not be directly addressed by our ICT-enabled solutions.

Additionally, literature highlights many unique challenges to CME in LICs. First, in many developed countries such as in Europe and America, CME is mandatory and its quality and participation are often warranted by a national board. For example, the Accreditation Council for Continuing Medical Education (ACCME) enforces standards and quality of CME, and requires recertification of medical professionals to maintain their licenses. On the contrary, in many LICs, there is no external enforcement of CME activities. As a result, there is no incentive for CME, or sanction for non-participation, except self-motivation. Other challenges include lack of time to participate due to pressures of work, lack of funded study leaves, insufficient financial support for external CME activities, limited access to CME content especially for rural medical professionals, lack of basic ICT knowledge required for accessing information online, and shortage of CME activities tailored towards individual needs [START_REF] Ogbaini-Emovon | Continuing medical education: Closing the gap between medical research and practice[END_REF]. These challenges are even greater in rural areas. For example, most rural medi-cal professionals do not have access to up-to-date CME content due to unavailable or unreliable internet access. Medical practitioners who work in rural hospital and clinics generally prefer local access to CME to reduce travel time and avoid absence from work. When many have access to computers, they would need support to use it for CME [START_REF] Butterworth | Retention of general practitioners in rural Nepal: A qualitative study[END_REF].

Considerable effort and research have focused on promoting CME content sharing in LICs. Research4life1 provides free or low cost online access of scientific research content for LICs. One of the Research4life programs, the Health InterNetwork Access to Research Initiatives (HINARI) 2 offers free access to up-to-date biomedical and health literature for health and medical institutions in LICs. While it postulates a way of supporting online access to CME content, it does not address the issues of limited internet connectivity and lack of basic ICT knowledge among medical professionals in LICs. For example, there are often difficulties in logging into HINARI and many participating organizations experience problems of organizing password distributions [START_REF] Smith | Access to electronic health knowledge in five countries in Africa: a descriptive study[END_REF] even when there is internet connectivity. Our CMES design not only presents a novel solution towards offline CME knowledge sharing and distribution, but also ensures CME content update when internet is available.

Citizen-Centric Capacity Development (CCD) Framework

In this research, we adapt the initial citizen-centric framework for ICTE capacity development [START_REF] Thomas | A Citizen-centric framework for ICTE Capacity Development in Haiti[END_REF] to guide our solution design and evaluation. Two key strengths highlight the rationale for its adaptation: citizen-centric requirement engineering and a pluralist research design. The revised CCD framework for ICT4D (Figure 1) involves two similar phases. Phase 1 adapts the citizen-centric approach [START_REF] Van Velsen | Requirements engineering for e-Government services: A citizen-centric approach and case study[END_REF] for ICT capacity development. Phase 2 is the evaluation and interpretation of the effective use and benefit of ICT. Below, we highlight and justify the main changes in the revised CCD framework, while interested readers can refer to the original framework (Thomas and Li 2015) for detailed definitions and steps. First, we consider that the citizen-centric approach for capacity development from the original framework is essential for linking ICT with development. In the context of development literature, capacity development can be defined in a wider context as "…the process through which individuals, organizations and societies obtain, strengthen and maintain the capabilities to set and achieve their own development objectives over time" [START_REF] Wignaraja | Capacity Development: A UNDP Primer[END_REF]. In ICT4D where many diverse and competing actors are involved in development, it is critical for an engaged outsider (i.e. ICT solution designers and developers) to understand and support local people to determine their own societal goals and challenges, build the capacity through ICT-enabled solution implementation that help the community achieve positive societal changes, and organize community members to act upon and sustain these changes [START_REF] Eade | Capacity building: who builds whose capacity?[END_REF]. Thus, it is desired to involve local people from the start of ICT solution development through citizen-centric requirement engineering (Phase 1 of Figure 1). Second, we believe that innovative design and effective evaluation of ICT-based intervention are two integral parts of ICT4D research. The ICT-enabled development goal can only be achieved through dynamic integration of social, psychological, and technical mechanisms in the ICTsolution design and evaluation. Such integration requires different research methods to address different tasks and research problems. The initial framework provides a strong foundation by systematically combining qualitative, quantitative, and design science research methods. We further revised the framework to address some of its limitations. First, it does not explicitly capture the ultimate goal of the ICT-based intervention in LICs, which is the social-economic development of local community. An ICT4D project should start with a clearly defined societal goal that can be potentially addressed by an ICT solution. Furthermore, while the complex socio-economic, political, cultural, and financial factors should be examined to achieve the potential benefit of the ICT-based intervention, an ambitious yet achievable ICT4D project goal needs to be described. An achievable project goal serves two purposes. One is to provide the basis for searching existing information and knowledge base that would inform the ICT solution design. The other purpose it to guide the research design towards evaluating the effective use of societally-beneficial ICT-based intervention. This goal-oriented design and evaluation process is incorporated in the improved CCD framework. Second, the original framework assumes the evaluation and interpretation of effective use and benefit of ICT (Phase 2 of Figure 1) to be quantitative. Often, ICT4D projects present intangible outcomes that can be difficult to define and measure quantitatively. Further, even when a project has clearly defined short-term goals, it is hard to articulate well-defined metrics to measure its long-term benefits. Thus, a good project evalua-tion should be resilient to accommodate multiple methods, capture changes over time, and be scientifically sound [START_REF] Lannon | An evaluation framework for ICT capacity building projects Action research in Armenia[END_REF]. The updated CCD framework reflects the multimethod approach towards evaluation and interpretation for ICT capacity building.

CMES Project Background

In this section, we describe the background of CMES3 project. The project was initiated by a group of medical doctors in Nepal, who advocate improving rural health care by focusing on training rural health care workers, especially those in hard to reach villages in the Everest region. As an underdeveloped country (145th of 188 countries in the Human Development Index) [START_REF] Jahan | Human Development Report[END_REF], Nepal faces great challenges as medical resources are extremely limited and infrastructure for the delivery of health care is fragile. As a landlocked country between India and China, 83% of Nepal's terrain is mountainous and about 80% of the population lives in rural and remote areas. Despite years of efforts to expand Nepal's telecom market, infrastructure development in the rugged high altitudes of the Himalayas is extremely difficult. Furthermore, the political instability (25 prime ministers in just 26 years of democracy) has had an adverse effect on Nepal's already struggling economic situation.

In the context of health care, World Health Organization (WHO) identifies Nepal with a critical shortage of health care providers with only seven providers per 10,000 capita. There is also a huge gap between urban and rural health care, where rural population has very limited access to doctors and hospital services. Lack of professional development opportunities is one of the main reasons for reluctance among medical practitioners to serve in the rural areas of Nepal [START_REF] Butterworth | Retention of general practitioners in rural Nepal: A qualitative study[END_REF]). Based on interviews with Nepal medical practitioners, one of main challenges to CME is that it is not mandated by the medical standards body (i.e., the Nepal Medical Council). This results in localized medical practices with great disparities between rural and urban areas.

The inception of the CMES project was inspired by the Computer-on-a-Stick (COS) solution that we developed for schools in Haiti [START_REF] Thomas | A Citizen-centric framework for ICTE Capacity Development in Haiti[END_REF]. One of the doctors who came across the COS said:

"The wisdom of the Haiti COS project is providing learning resources for students without the need for an Internet connection. In countries where Internet connection and electricity are unreliable...this leaps over the limiting step to access CME content. This is a common problem in Nepal where load shedding occurs daily for 12+ hours and for days in the rural areas. I started thinking about using the same model for medical education."

While CME covers many areas, CME in Emergency Medicine (EM) was identified as an immediate need because Nepal has a large ethnic population living in the mountainous regions and is a popular destination for adventure travelers. EM is one of the newest and fastest developing medical specialties in Nepal. Yet, national standards in EM training and certification have not been developed or mandated. While major urban hospitals start to adopt EM practices and training, the emergency care is entirely lacking in rural areas [START_REF] Pandey | Emergency medicine in Nepal: present practice and direction for future[END_REF]. The excessive mortality in the recent 2015 earthquake is a direct testament to this dire situation. One of the doctors described the needs for EM training in Nepal as:

"From remote villages to larger cities, my experience has been a lack of quality and affordable EM CME for all health providers including nurses, rural community health workers (CHW), midwives, and physicians. I realized my EM training and wilderness medicine background provided pertinent topics for Nepal's austere environments...the villages and even the cities... Kathmandu is an austere environment considering strikes, earthquakes, the petro embargo and rush hour traffic."

Initial target participants were also identified, as described by one of the doctors: "In Nepal, the target audience will be rural health providers, nurses, midwives, first-year interns, residents, or interns that are unable to secure one of the few residency spots in a specialty. The only EM residency program in Nepal that I am aware of is at Patan Hospital and it only has four positions open to GPs (General Practitioners) who have EM experience. Residency programs in all specialties are scarce in Nepal and residents pay tuition level fees during their training. Often, it is only the wealthy or well-connected that can afford to continue their studies. The city and town Emergency Departments are staffed by GPs and interns. The village health posts are staffed by nurses and CHW. These should be the target practitioners."

After obtaining the support from a world-class CME content provider, and multiple medical administrators at hospitals and clinics in Nepal, we assembled a project team to investigate potential ICT-enabled solutions for CME in LICs with the goal of using Nepal as a test bed. In the following section, we describe the CMES project that is guided by the first phase of the CCD framework. The project has gone through multiple iterations of ICT artifacts design and testing, and initial CMES-based capacity building. At the time of this paper submission, we have initiated the second phase of the CCD framework, which is the qualitative and quantitative evaluation of CMES use and benefit. The second release that includes an improved CMES software targets launch in nine rural and urban locations in January, 2017.

CMES Platform Development

CMES Project Goals (Phase I)

The CMES project started with a clear societal goal from local medical practitioners in Nepal, which is to improve the rural health care by providing affordable and quality CME content for rural health care workers. The local doctors also suggested a potential ICT solution that is similar to COS to solve the problem of accessing CME content with limited or no Internet connectivity. In order to translate this societal goal to an ambitious, achievable and measurable ICT goal, we first consulted the knowledge base related to offline content delivery and CME challenges in LICs and rural areas. Among existing offline content delivery solutions, Internet-in-a-Box and RACHEL-Pi4 are two alternatives for the delivery of educational contents without the need for Internet. There is also E-Pustakalaya solution 5 that provides education-focused free and open digital library for rural schools and can be installed on low power servers with limited or no Internet connectivity requirements. However, none of these solutions include CME content. Furthermore, all of them offer pre-loaded static content, and content update is quite cumbersome. The previous COS solution is also not desirable, as it requires the Linux computing environment and focuses on K-12 education rather than professionals in the medical field.

In addition to literature review as highlighted in Section 2, we also consulted stakeholders (e.g., medical administrators, NGO leaders who share similar interests, government officials, and medical policy makers) and citizens (e.g., medical doctors). Interviews with medical administrators (including senior medical doctors) and NGO leaders confirmed the literature findings. For example, the most common challenge for CME in Nepal is the lack of regulatory requirement for CME, as highlighted by the founder of a community-based, not-for-profit hospital:

"Like many developing countries, CME in Nepal is not mandated by the authorization body (Nepal Medical Council) and there is no CME standard. It becomes a voluntary effort of the director of each department to implement CME... The CME goal will be (even) different from department to department in the same hospital. This results in the localized medical practices (knowledge sharing usually happens at the individual department level) with great disparities between Urban and Rural areas."

The interviewees also identified many social, political, and financial factors critical to the success of CME, such as administrative support, mentoring and encouragement, access to relevant and update-to-date CME content, policy incentives, and intrinsic motivation of medical practitioners. For example, a NGO Leader describes the issue of self-motivation as:

"The medical practitioners would be more encouraged to work in rural areas if they feel connected with the main/urban hospitals. The practitioners must be motivated from their heart to adopt and use CME. Otherwise it would be too difficult to implement it. We can encourage them for sure telling that it will help for their career but that is not good enough. If the practitioners are interested to work just for money, we can't motivate them."

Although not all of these identified factors can be addressed by ICT-based intervention alone, they should nevertheless be considered in a broader context for CME capacity development. For example, we met with the Secretary of Health at Nepal Central Government and the Director of the Medical council as it is the government's responsibility and interest to improve the rural health. Keeping them aware and re-ceiving their support are essential for the long-term development and sustenance of a project of this nature.

Our interviewees included not only initial targeted participants, but also doctors who work in the participating urban hospitals and medical clinics. All interviewees provided valuable input in shaping our project goals. For example, one western doctor who volunteers at an advanced travel clinic in Kathmandu mentioned that access to medical content was really not an issue there, as they had high speed internet and subscription to content services. However, she knew many different groups and people who are interested in promoting rural health services in Nepal. she suggested the need for a platform to brings those players together and distribute CME with various entities, groups, and organizations that share the same goal.

Informed by existing knowledge and voice of the local people, we defined our project goals as: "provide free and open access to CME content in LICs, and promote standardized CME knowledge sharing and distribution". Based on these goals, we targeted the development of a low-cost, adaptable CMES platform that include:

• A CME content storage solution that capitalizes on Internet-based modalities for provisioning CME content; • A CMES software application that enables CME content dissemination and synchronization with minimal need for Internet connectivity; • An offline CME content server based on raspberry-pi where content can be accessed when Internet connectivity is unavailable or insufficient for most practical purposes; • and a LISTSERV for participants to discuss CME related topics.

The team also acknowledged that promoting standardized and localized CME content sharing requires a long-term commitment from multi-functional and multicultural teams. Many key stakeholders were identified and brought into the project as partners and advisers.

Citizen-centric Requirement Engineering (Phase 1)

Once the project goals were articulated and a set of potential ICT solutions were identified, we started the citizen-centric requirement engineering for the CMES software application development. It included iterations of citizen and stakeholder interviews, analysis, user requirement, low-fidelity prototype development, and citizen walkthroughs (Phase 1 of the CCD framework). The citizen-centric approach ensured the design and construction of CMES application met the vocalized needs of local medical practitioners. Interviews with stakeholders identified three design principles for our application:

• Free: the CME content is delivered for free to the users;

• Adaptive: the CME application is adaptive to the user's device modality;

• Ease-of-use: the application should look and feel like something they already know how to use and require minimal training.

Citizen interviews provided insights into key features that were desired for the CMES application:

• Content on CMES should be updatable when internet is available (e.g. when a rural doctor goes to a location with internet connectivity); • A search function that enables the quick identification of content by tags or keywords; • Display storage information of the USB drive;

• A personalizable and customizable local CME library structure that enables the user to retain CME topics of interest and delete irrelevant or unused ones.

Because the CMES application was envisioned to require a computer to operate, it was critical to understand the types of computers (including hardware and software) that users might have. Having conducted a survey and visited the hospital sites in Nepal, we found out that 100% of targeted users were using Windows machines, among which 60% were older than 4 years and 20% were running Windows XP operating systems. This brought some system constraints in the application development, such as: • How to ensure version management across different operating systems?

• How to ensure the application runs the same and effortlessly across different machine? • How to make sure that the application will retain the same user experience in different types of operational systems?

Figure 2 depicts our CMES architectural design. The CMES application was written in Java. For content storage and management, we used Microsoft Azure, a scalable cloud-based computing platform with integrated tools and managed services. Our project takes advantage of its built-in server management, security, availability, and scalability features. Soon after the initial architectural design was finalized, a low-fidelity prototype including initial application screen mock-ups was presented to the citizens for feedback. For example, three different content viewing structures were presented to the citizens and they all chose the tree-view (commonly seen in windows operating environment) which they felt most comfortable with. The citizen walkthrough also inspired additional design features for the CMES application:

• A launch screen with links to tutorials in pdf and video format;

• Focus on simplicity of use (e.g., a landing page following the launch screen with two options: Search and Sync); • Sync feature activated only when Internet is available;

• USB write-protection to prevent accidental content deletion and safe guard intellectual property of CME content provider; • Packaged Java Runtime Environment (JRE) within the application (during the low-fidelity prototype testing, it was found that many computers in Nepal hospitals did not have JRE).

Figure 3 presents a snippet of our application launch screen and interested readers can explore more about the CMES by viewing the video tutorial6 .

Figure 3. Application Launch Screen

Based on the feedback from citizen walk through and analysis, many changes were made to the initial prototype. For example, the look and feel of the initial screen was refined and tailored as shown in Figure 4, which was well received during the citizen walkthroughs. Some additional features were designed for software usability. For example, Nepal does not have reliable Internet connections, especially in rural areas. An Internet connectivity indicator was therefore added at the bottom of the screen. As the CMES project continues to evolve, the citizen's needs and preferences have become more articulated, and the supporting software infrastructure and application design have expanded. For example, all screens automatically resize to match the display resolution of the viewing device and tooltips added to guide user interactions. Each CMES content type included a file type logo and a simple click of the file would invoke the default application registered with the computer's operating system. Because Internet speed is a challenge in Nepal, a status bar was added to indicate both percentage and number of files downloaded or deleted. In the event of Internet failure during download or delete, the application will roll back to the previous state.

CME Capacity Development (Phase 1)

After multiple iterations of software development and two field visits (two weeks each) by the researchers and CMES developers to Nepal, the CMES program was officially launched during Fall 2016. A medical doctor dispensed USB drives to the participants and provided CMES training. The training of doctors was conducted at hospitals in Kathmandu. It consisted of either one to one training session or a Power Point group presentation, which included instructional documents and video, and hands-on demonstration of the CMES application. This was followed by a question and answer session, during which the participants were given time to practice using the software. For participants who were unable to attend training in Kathmandu, their organizational administrator was trained to demonstrate and train the medical staff on site. Troubleshooting and follow-ups were encouraged via phone, Skype and email. Six organizations participated in the initial launch with a total of 25 hospitals and/or clinics sites and 39 participating medical practitioners. All participants were physicians, among whom more than half were working in remote and rural areas of Nepal. Since the completion of onsite training, 80 additional medical practitioners have expressed interest in the CMES thumb drives. Two rural hospitals, one in Lukla and one in Chitwan, have submitted requests to participate in the CMES project. We anticipate approximately 100 thumb drives to be distributed among medical practitioners in Nepal by January 2017 to meet the demand.

As described preciously, ICT-enabled capacity building in LICs has to be deeply embedded in its social, economic, and political environment [START_REF] Eade | Capacity building: who builds whose capacity?[END_REF]. Successful ICTenabled capacity building requires the balance of ambitious yet achievable ICT goals with the long term societal goals. Slower than expected pace of measurable outcomes is expected when developing ICT solutions for challenging environments [START_REF] Agyemang | NGO accountability and aid delivery[END_REF]. The capacity development in Phase 1 (Figure 1) of the CCD framework is not just about delivering the ICT solution to end users. Rather, it requires strategic consideration of social and psychological mechanisms that need to be addressed to achieve the effectiveness use of ICT. The CMES project is no exception.

The success of the initial CMES launch is attributable to a couple of factors. First, the CMES project is a multi-functional, multi-cultural collaboration effort that has engaged many different stakeholders from the start. This allowed us to identify voluntary participants and seek administrative support from partnering hospitals. Second, meetings with the Nepal Medical Council and several senior doctors confirm impending policy changes related to CME in the near future. According the director of Nepal Medical council, the council is committed to introducing CME mandate in Nepal, and has already created a committee to initiate the necessary steps. Although the CMES program will not directly influence such a policy change, the director viewed the proposed solution as a valuable asset to deliver customized, updatable and personalizable CME knowledge library. Third, the application design benefited greatly from involving citizens in the process. The functionality and simplicity of the software was very well received. All participants commented on the ease of use, navigation, and clickand-go features of the software. Fourth, we were able to engage several key stakeholders who are well respected senior doctors or NGO leaders in Nepal. They served as local champions for the project and helped us connect with many medical intuitions. For example, a chief medical doctor in a rural hospital sent the following email:

"I am super excited to hear about your CMES program, exactly something that is greatly lacking in this remote part of the world. Thank you so much for your kind interest in including us in this program. I am sure it will give very useful medical information for our team up here and truly will be well used in this remote hospital."

Last but not least, long before the design and building of the CMES application, we opened dialog with various stakeholders regarding CME challenges and factors to be considered to ensure the success of CMES program. The level of commitment and belief in the potential societal benefits of CMES varied significantly among those stakeholders. One of the NGO leaders with enormous experience in training rural health workers noted "…mentors and administrative support are an important component of any training and CME program." As such, we carefully evaluated the needs of participating organizations, which include regional and district hospitals, medical clinics, and health centers. One of the hospitals initially expressed interest in participating in the CMES program, but later showed little engagement and administrative support. Subsequently, although keeping them in our participants list, we only provided one USB drive to their chief EM officer. On the other hand, the experience at another hospital was awe inspiring. The hospital's director is passionate about improving rural health and the hospital has an aggressive in-house CME program for their nurses, plastic surgery residents, staff doctors, and house officers (those who have graduated from medical schools but not completed residency). The lead doctor not only engaged all available staff in the initial CMES program launch, but also suggested co-developing CME content. We consider the capacity development at their site a success, as described by the medical doctor who provided CMES training at their site: "... arranged a conference for all available staff so I presented the CMES program not only to ED [emergency department] doctors but the critical care, surgery and medical teams. They are all interested in CMES. They consider the thumb drives as property of the hospital and are treating them like a library book to be borrowed. The ED Director and the CEO will each have a thumb drive. Any other doctor is welcome to use one for a two-week period of time so they will circulate between the departments. Then they have to present one article at their CME conference."

Effectiveness and Benefit of CMES (Phase 2)

The evaluation of CMES program towards achieving its ICT4D goals has been initiated. We plan to include both qualitative and quantitative methods to evaluate the adoption, effective usage, and benefits of our CME platform. The CMES application includes extensive logging features to track usage patterns of each device, such as frequency of application launch, synchronization, content viewed, and search behaviors. The logs are uploaded to remote server any time the CMES sync operation is triggered, which will enable us to conduct varying levels of assessment related to the ICT usage. A follow-up questionnaire will be sent to each participant. They will be encouraged to provide comments and criticisms on how the program can be improved to meet their CME needs. Qualitative in-person interviews are planned in May 2017 to determine whether and how CME access has impacted practice patterns, physician identity, and professional networking. We expect a longer period of time for participants to see the societal-benefit of the CMES. We also plan to have post implementation meetings with stakeholders for future recommendations. Moreover, we are currently in the process of reviewing theoretical foundations of CME, such as experiential learning theory [START_REF] Kolb | Experiential learning theory: Previous research and new directions[END_REF] and transformative learning theory [START_REF] Mezirow | Transformative learning: Theory to practice[END_REF], to help us better understand the CMES program adoption and usage.

Conclusion and Future Research

We developed a low-cost, adaptable platform for the delivery of CME content for medical practitioners in LICs. The initial implementation of CME content server and the USB-based CMES software application for capacity development was conducted in Nepal. While planning the second iteration of application release and continuing CME capacity building, the evaluation of capacity building effort has also started. This research contributes not only to the theoretical knowledge of linking ICT and development in ICT4D solution design and evaluation, but also the practical knowledge of building ICT-based CME capacity for rural areas in LICs.

For the future research, we have started prototyping two other components of the CMES platform: a CMES-pi offline CME content server based on raspberry pi and a LISTSERV. The CMES-pi solution will include a content server that can be updated remotely, and a mobile application that will allow medical practitioners view CME content on their mobile devices. A needs assessment is planned to identify CME content needs of the rural healthcare workers. It will provide us insights on how to expand CME to other medical specialty areas, such as nursing and pediatrics. As suggested by the secretary of Nepal Health Services, we plan to engage Nepal Medical Association and Nepal Nursing Association for participation from those specialties. We also plan to provide a web-based, Internet dependent CMES version for urban doctors in LICs, who are also often constrained by limited CME resources. To encourage participation, we are in the process of designing feedback loops, such as certificates of completion when CME content is reviewed and related questions are answered. As described on our website, the long-term project goals include engaging a global community to contribute core CME content for free in many languages, and benefit the public health in a global context. We are currently reaching out to agencies in other LICs for CMES program participation.

Figure 1 .

 1 Figure 1. Citizen-centric Capacity Development (CCD) Framework

Figure 2 .

 2 Figure 2. Initial CMES Architectural Design

Figure 4 .

 4 Figure 4. Application Landing Screen

http://www.research4life.org/

http://www.who.int/hinari/en/

www.cmesworld.org

https://racheloffline.org/

http://www.olenepal.org/e-pustakalaya/

https://youtu.be/qyvZOC4c85I

Acknowledgements

We thank the Fletcher Jones Foundation (FJF), Claremont Graduate University (CGU), and Virginia Commonwealth University (VCU) Undergraduate Research Fellowship for funding in this research, and the Microsoft Research Grant for providing the Azure Sponsorship to support our ICT infrastructure needs.