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Participatory approaches to information systems design have evolved over approximately the last three decades, mainly in Scandinavia, Europe, and lately in the US. However there has been limited and peripheral research and debates over participatory design approaches and techniques in developing country settings. This paper explores three case studies in developing countries where participatory approaches have been used in the design and implementation of health information systems. The investigation reveals the politics of design, the nature of participation, and the methods, tools and techniques for carrying out design projects are shaped with respect to the diversity of the socio-economic, cultural and political situations faced in each of these settings. Though common strategies, such as capacity development, could be found that cut across the three case studies it is the importance of the contextual nature of participatory design that emerges most strongly. There is no single algorithmic best practice regarding participatory design in information systems which is applicable to all situations.