Trends: Global Health and Design for Social Impact

Jaspal is now back in Mongolia finishing up some research and I am posting this for him. He is a design expert and I am just beginning to learn about the impact of design on pretty much everything. In both development and public/global health communities design theory is a foreign concept that is not discussed formally. However, as we will detail in future posts, the impact of design on human behavior is profound (read more here). We should be paying attention to this because of its importance and ability to have a critical impact. More details on design and public health in future posts. In the meantime, organizations like PATH, GATES and the Rockefeller Foundation are just beginning to pay attention to design – you will be hearing a lot more about this in the future.

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By Jaspal, cross-posted from Design Research from Health:

Just after the Global Health Council Conference and just before coming to Mongolia, I attended the “Design for Social Impact Symposium” in New York (photo below), a joint project of the Rockefeller Foundation and IDEO. Thanks to Aman for pointing out that this event has been covered by Jocelyn Wyatt and Rob Katz. The symposium was based on the work of Jocelyn and Aaron Sklar, both of IDEO, who developed ideas about how design can play a larger role in social impact.

I had planned a detailed post about this event, but I left my notebook at home in Oakland, so this is the abbreviated version.

The two key outcomes of this meeting were, in my opinion:

1. a conceptual foundation for how the design industry can participate in social impact work
2. a network of key players in this space

The attendees included design firms (IDEO, Frog, Jump), consulting firms (BCG), NGOs (WaterAid, Design that Matters, PATH, Unitus), foundations (Rockefeller, Acumen, Gates), universities (MIT, Srishti, Duke, Berkeley), and others (World Bank, Cooper-Hewitt). [That’s not a complete list of attending organizations, just the ones that came to mind.] I must say that I was impressed, not just by the institutions, but by the individuals representing those institutions. These were some really good people, with some really solid experience.

The meeting was based on IDEO’s findings and resulted in two publications, which they have made publicly available. But it was also about sharing experiences of the other attendees. The one prompt that I remember most clearly, more of an ice breaker really, was about goats. “In our experience, there’s always someone in the room who has done projects with goats. Who here has worked with goats?” Two hands raised out of forty.

The underlying assumption of the meeting was that the design industry has a role to play in social impact, not just design as a concept or process (I agree, by the way). Based on that assumption, the discussion was about meeting the goals of social good while still operating a business. Several people from design firms talked about internal pressure from designers who want to do social impact work, not just projects for large, corporate clients.

I pulled a few excerpts from the IDEO + Rockefeller Guide:

What they looked at:

How can design firms make social impact work a core part of their business? How can we collaborate with organizations that are highly resource constrained? How can we redesign our offerings to become more accessible to social sector organizations? This initiative is focused on the process around doing this work, rather than the content of the work itself.

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How they did it:

The Rockefeller Foundation invited IDEO to conduct this exploration starting in February 2008. We spent the first two months interviewing people involved in social sector work. We had inspiring discussions with foundations, social entrepreneurs, NGOs, professors, writers, students, designers, and consultants. The conversations examined the role design could play in this sector, how design fi rms might work with social sector organizations, and how we could maximize our impact in this space. Observations and interviews were conducted in offices, at conferences, and on the phone, and brought the team to Bangalore, Bombay, New York, Oxford, Palo Alto, Pune, San Francisco, and Seattle.

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Definition of social impact:

To designers, it is about the impact of products or services on individuals and groups of people. We look at the broader impact of all of the design work we undertake. We think about balancing the needs of the individual with the needs of the overall community. On every design project, we can consider the triple bottom line and take into account social, environmental, and economic impacts.

Market Failure and the Clear Need for Electronic Health Records

The New York Times reports that Most Doctors Aren’t Using Electronic Health Records. However, the New England Journal of Medicine study released June 18th notes paradoxically “doctors who use electronic health records say overwhelmingly that such records have helped improve the quality and timeliness of care.” The benefits are overwhelmingly positive: “82% [of doctors using electronic medical records] said they improved the quality of clinical decisions, 86% said they helped in avoiding medication errors, and 85% said they improved the delivery of preventative care.” Clearly, electronic medical records could be a tremendous aid in improving health outcomes, shifting the balance of care from costly medical intervention to relatively inexpensive prevention measures, and reducing medical errors.

“Yet fewer than one in five of the nation’s doctors has started using such records.” Only 4% of doctors surveyed were using “fully functional” electronic records that can record clinical and demographic data, results of lab tests, issue orders and inform clinical decisions (such as warning about drug interactions). 13% of respondents reported using a “basic” clinical system, which lacks clinical decision support and some order-entry capability.

The barriers cited are largely economic, with doctors in small practices citing prohibitive capital costs for adopting a new system, lost income from not seeing patients, and no existing electronic medical record software that meets the needs of small to medium practices. In an attempt to speed adoption, the government has announced a Medicare program that will offer incentives to practices to transition to electronic medical records.

“What we see is a deficit in innovation, and that is something innovators and the capital markets can address,” said Dr. David J. Brailer, who leads a firm that invests in medical ventures, Health Evolution Partners.

After conducting several retrospective folder reviews, I believe the conventional patient folder is actually an obstacle to good patient care. Folders are often lost or duplicated, and they take time to retrieve. Basic patient information is duplicated in every physician’s notes, handwriting is often illegible, there is no alert system for medication errors, guidelines for patient management, or flags for unusual findings or reminders on lab results. Despite a fully integrated health system in South Africa, the reliance on paper records causes fragmentation of patient information, and disrupts continuity of care.

Why go with paper when you could have electronic medical records?

“Design Thinking” in Harvard Business Review (Tim Brown)

Cross-post from Design Research for Health: Mongolia:

 

Saw this over at Jocelyn Wyatt’s blog:

IDEO’s CEO, Tim Brown, wrote an article for June’s Harvard Business Review. This is a great introduction to design thinking.

If this link doesn’t work, go to the HBR website and look for the “Design Thinking” link.  Currently it is accessible as free content.

Brown does a great job of showing how thinking in design terms has value beyond products.  Services, processes, systems, experience, strategy can all benefit from design thinking.  And even with products, it’s not just about defining requirements in the late stages of the game, it’s about innovation:

 

Although many others became involved in the [Shimano “Coasting”] project when it reached the implementation phase, the application of design thinking in the earliest stages of innovation is what led to this complete solution. Indeed, the single thing one would have expected the design team to be responsible for—the look of the bikes—was intentionally deferred to later in the development process, when the team created a reference design to inspire the bike companies’ own design teams.

 

A couple extensions to Brown’s statements about the Aravind Eye Care System:    

 

Much of its innovative energy has focused on bringing both preventive care and diagnostic screening to the countryside. Since 1990 Aravind has held “eye camps” in India’s rural areas, in an effort to register patients, administer eye exams, teach eye care, and identify people who may require surgery or advanced diagnostic services or who have conditions that warrant monitoring.

 

In developing its system of care, Aravind has consistently exhibited many characteristics of design thinking. It has used as a creative springboard two constraints: the poverty and remoteness of its clientele and its own lack of access to expensive solutions. For example, a pair of intraocular lenses made in the West costs $200, which severely limited the number of patients Aravind could help. Rather than try to persuade suppliers to change the way they did things, Aravind built its own solution: a manufacturing plant in the basement of one of its hospitals. It eventually discovered that it could use relatively inexpensive technology to produce lenses for $4 a pair.

First, Aravind did try to persuade suppliers to change the way they did things.  The promise of a huge latent market was not convincing enough for existing suppliers to drop the price of their intraocular lenses (IOL).  It was then that Aravind built its own capacity to produce lenses, in what came to be known as Aurolab.  I would argue that both their attempts at negotiation with IOL manufacturers and their decision to produce their own lenses were reflective of design thinking.

Second, what Aravind did with outreach was based on the prior activities of the Dr. V and the other Aravind founders.  As far back as the 1960s, they were conducting eye camps while in government service.  The key innovation was a management one: changing from in-the-field surgery to screening patients and transporting them to hospitals for surgery.  This greatly reduced the burden on technical resources (surgeons and technology) and made patient followup easier.

Global Health Council 6: Reflections on the Conference

One final post on the Global Health Council Conference.  I wanted to wait a few days so that I’d have some room to reflect on the last week.  Here are my lasting observations from the conference.

1. International crowd. I was pleasantly surprised by the significant international attendance at this conference.  Based on an accumulation of experiences, I think I had set my expectations low.
2. Sharing the conference. Through kaisernetwork.org, globalhealthtv.org, and sharing presentations, the Global Health Council is pulling its weight in terms of dissemination and sharing.  But it doesn’t need to stop there.  The reason I blogged so actively from the conference is to share the experience, the discussions, and the debates with those in the global health community who were not there.  It’s great that the GHC is doing its part, but it’s up to the participants to take it one step further – not simply to report on it, but to provide commentary, to tie together disparate threads, to engage a wider community in timely discussions.  The last conference I attended before this was CHI 2008 (Human Factors in Computing) in Florence. CHI and GHC each had about 2000 attendees and both are well-respected conferences.  But the former has significantly more content in the blogosphere (5-10x).  The tools are free and accessible, so I don’t buy the excuse of CHI being more tech-savvy.  It is about the importance we place on sharing information.
3. Listen to the people. This was a theme that kept coming up throughout the conference (see each of my previous posts from the conference).  Probably related to both the community health theme and a realization that we have historically done a poor job of understanding people and communities in global health.  Not just listening to people, but re-emphasizing primary healthcare, localized systems, and the merits of patience.
4. There’s more to it than health systems.  The discussions focused largely on health systems and not enough on other aspects of public health.  (I am complicit in this – the work I was presenting was well within the framework of health systems.)
5. Where’s the rest of the West?  All of Seattle was there, but very few people besides.  From California, there were only 4 from Berkeley, 2 from UCSF, and a handful from the rest of the state.  Also, other than North America, the Western Hemisphere seemed to be MIA (besides my Bolivian roommate).
6. Technology is not neutral.  The way people at the conference were talking about technology – e.g. PDAs and LifeStraws – assured me that technology has maintained its magical allure.  We need to deal with technology the same way that we deal with branding in microfranchising, social marketing of condoms, and HIV/AIDS IEC campaigns.  That is, we need to determine what will be most effective by understanding how people value and perceive technology.  And we need to realize that, like any innovation, there will be different solutions for different places.

Foreign Assistance from the 1960s

You know what happened in the 1960s? Here are several things:

• The first debate for a presidential election was televised.
• The Soviets sent the first man into space and the Americans need a man in space, too.
• The Berlin Wall was built.
• The Peace Corps was launched.
• Rachel Carson warned that our earth would die of pollution and chemicals.
• Martin Luther King Jr. made the speech, “I have a Dream”.
• The first Civil Rights bill was passed to stop racial discrimination.
• President Johnson ordered bombing raids on North Vietnam.
• Woodstock happened.
• Malcolm X, JFK and MLK were assassinated.

The other thing that happened – the passage fo the Foreign Assistance Act. See the below short video and campaign for why this is important:

For more on this very cool video by CGD see their website devoted to this here and think about signing their petition. They also have a great set of blogs, the health one (Global Health Policy) is here.

Global Health Council 5: We ♥ Margaret Chan

Friday ended with an impressive lineup of global health leaders discussing the disconnect between horizontal and vertical funding in the plenary session titled Meeting Along the Diagonal: Where the First and Last Mile Connect.  A webcast of this session, and 2-3 others from the Global Health Council Conference, will be available on kaisernetwork.org starting Tues-3-Jun-2008.  It’s nearly 2 hours long, but brings together ideas from the Gates Foundation, WHO, the Global Health Council, and USAID.  As much as it was about these organizations and the types of organizations (foundation, multilateral, advocacy, bilateral), it was about the individuals who spoke their minds:

• Jaime Sepulveda, Director, Integrated Health Solutions Development, Bill & Melinda Gates Foundation
• Margaret Chan, Director-General, World Health Organization
• Nils Daulaire, President and CEO, Global Health Council
• Henrietta H. Fore, Administrator, U.S. Agency for International Development, Director, U.S. United States Foreign Assistance

Victor Kamanga of the Malawi Network of People Living With HIV/AIDS was supposed to speak at this panel representing the community perspective, but was denied a visa by the United States.  Nils was brave enough to say that it may have been due to Kamanga being HIV-positive.

The session was moderated by Susan Dentzer, Editor-in-Chief of Health Affairs, and her performance – one that was witty, but neither overbearing or spectatorish – made more sense after I learned about her NewsHour and NPR roots.

Administrator Fore spoke of USAID’s accomplishments and left immediately for the White House.  The session was awash in metaphors related to the theme: diagonal (Sepulveda), fractal (Daulaire), circular (Gordon Perkin, in the audience).  Dentzer synthesized the overall position of each of the speakers in a few words (in order that they spoke):

• Fore: “horizontal aspects to vertical programs”
• Sepulveda: “integration”
• Chan: “connect”
• Nils: “fractal”

The collective message for me from the session was this: health systems are complex, we need to look at integrated solutions, and it will take time.

Sepulveda’s framework for looking at health systems requirements was his effort to “make that black box {of health systems] transparent”.  His four requirements of health systems are:

1. Stewardship
2. Financing
3. Delivery (personal and non-personal services)
4. Resource Generation (people, information, vaccines, technology)

He referred in his comments to 2 articles:

1. Walsh J A & Warren K S. Selective primary health care: an interim strategy for disease control in developing countries. N. Engl. J. Med. 301.967-74, 1979.
2. An “forgotten” article that Sepulveda wrote in the 1980s in the Bulletin of the WHO on the topic of “diagonalism”, but perhaps not in those words.  (I wasn’t able to find it, but if you know of the article, please post a link as a comment.)

Both Sepulveda and Daulaire had some interesting things to say, but I want to focus on Margaret Chan.  About 2/3 of the way through the sesssion, I was so taken by Margaret Chan’s honesty and perspective that I wrote “I ♥ Margaret Chan” in my notebook.  I passed my notebook to an NIGH colleague sitting next to me, who then showed me his notebook which had “I [heart] Margaret Chan” written atop his penultimate page of notes.  He didn’t want to draw a heart, he later told me, because he was afraid somebody might see it.  If that wasn’t weird enough, I told the story to another NIGH colleague, who responded that she too had written “I ♥ Margaret Chan” in her notebook.

Some Margaret Chan highlights (keep in mind her emphases in her tenure at the WHO have been Africa, primary healthcare, and women)

• Dentzer told her she was “the James Brown of global health”, a reference to her work ethic
• “What works for Hong Kong doesn’t work for Zambia.”  This sounds obvious, but there was quite a lot of talk at this conference about exporting successful models from one country to another.  I’m not saying you can’t learn from successes, but there is at least some better work we need to do in adapting those models to different situations.
• “Primary healthcare faded from the vocabulary of global health.”  She cited Periago’s “crushed” comment from earlier in the day.  In fact, she brought in a lot of examples of what other people were saying throughout the day, so it’s clear that she was listening.
• One of the other examples she brought up was a Johns Hopkins professor who in a morning comment advocated for “health impact assessments” like “environmental impact assessments” prior to doing something new.  (Sorry, don’t know the name of the JHU professor.)
• “Famous soft drink”.  She didn’t name it because she didn’t want to advertise for it, but asked “why can’t we get to the same areas of the world?” (a reference to technologies like vaccines and medicines).  If we can’t do that, “we fail our people”.
• “It’s easy to blame people when you fail.”
• In referring to her 30+ years of experience: “I look young, but I’m not”.
• “Primary healthcare was alive” in places like Brazil, India, and Argentina, even though it wasn’t in the “official vocabulary”.
• “I’m not going to repeat the WHO definition of health.  To me health is a social objective.”
• In indicating that we need to train more mid-level professionals: “For the clinicians in the audience, don’t worry, there’s plenty of work.”
• “We have not listened enough.”  “We underestimate the ingenuity of the community.” “If you say ‘talk is one thing, walk is another’, I rest my case.”
• “We are insular. We only look at the health sector.”  We need to look at safe water and sanitation, education, etc.
• “Ministry of Health [alone] cannot handle the complexity of the situation.”
• “Let’s be realistic. Even NGOs are making profits.”
• “Why is it that working with industry is seen as dirty?” “Industry is part of the solution.”  We need to work with food and pharmaceutical industries.
• Peer review is “another elephant in the room”- Chan identified most of the elephants.  It is a process by which “your friends condone your work”.

And my favorite, because it directly addresses the work I do and that we need to advocate for in the development of new technologies and services:

• “I didn’t realize that the color of bednets makes a difference.”
• “It wasn’t until we brought in the anthropologists that we found out that the color red represented death.”
• They changed the color to yellow and people started to use them.

I encourage you to watch the session if you can spare the time.  Posted from the Wi-Fi bus between DC and New York.