The promises and limits of standardisation through paper-based technologies: An ethnographic exploration of integrated management of childhood illness (IMCI) in Bangladesh

Integrated Management of Childhood Illness (IMCI) is a strategy that aims to standardise clinical assessment and treatment of sick children. In this article, we examine the aspirations and unfolding of introducing a revised IMCI strategy in Bangladesh. We carried out ethnographic fieldwork among project implementors and in IMCI health service delivery settings in Kushtia district, including 36 semi-structured interviews with policymakers, programmers and IMCI service providers. We focused on the IMCI register, a paper-based technology designed to guide health service providers to enact standardised treatment and decision-making during healthcare encounters. During its design, policymakers and programmers aspired to produce a register that would be simple to use and guide health service providers to enact care uniformly. However, simplicity was muddled by the range of agendas and negotiations around what should be standardised and how. In health facility settings, despite national approval, the register's legitimacy was ambiguous as it was perceived as a materialisation of an external project, and its introduction did little to reconfigure how providers enacted health care. However, it operated as a powerful material to make claims about the types of care that matter, as providers saw the work of completing the register as compromising their ability to do the highly valued work of interfacing with patients. Moreover, the register became a tool to negotiate and index intra-institutional hierarchies. Rather than pointing to project failure, these findings reflect the nature of technologies, which are always reconfigured within the systems and social worlds in which they are embedded.