Speculating with Care: Worker-centered Perspectives on Scale in a Chat-based Health Information Service

Seeking to address barriers to in-person care, governments and non-governmental organizations (NGOs) globally have been pushing for scaling chat- or phone-based information services that rely on care workers to engage with users. Despite theoretical tensions between care and scale and the essential role of care workers, workers' perspective on scale and its impact on care provision is rarely centered early on in decisions to scale. In this paper, we examine care and scale from the perspective of medical support executives (MSEs) who support a chat-based health information service for maternal and child health deployed across multiple states in India. We draw on observations of MSEs' work, interviews with MSEs, NGO staff who implement the service, and families who use the service, and speculative design sessions conducted with MSEs. We find that by centering MSEs' perspectives, we can differentiate between growth of the relationships and heterogeneity that enable social impact, versus scale-thinking that promotes the decontextualization of care. We leverage our findings to discuss implications for scale and automation in chat-based health information services, including the importance of human connection, place, and support for care workers.