Design Research for Global Health

Borrowing innovation: health services, financial services, and clean tech

Image courtesy of kiwanja.net

 

Cross-posted from the Global Health Ideas blog:

Late last week I read news from three different sectors, all about “South-North” innovation transfer, a topic we’ve discussed here before, particularly in the context of mHealth. Earlier this year Fast Company reported on the concept of trickle-up innovation, citing the examples of yogurt microplants in Bangladesh (Group Danone, Grameen Bank) and Mosoko, touted as Craigslist for the next billion in Kenya (Nokia). In addition to these cases of MNCs from the global North testing out concepts in the South, Fast Company presented examples of corporations from the South, including ICICI (banking, India), Natura (cosmetics, Brazil), and Goodbaby (infant products, China). 

Here are the three articles from this past week:

1. HEALTH SERVICES: To Fix Health Care, Some Study Developing World, Wall Street Journal, 2 Jul 2009. The University of Alabama-Birmingham AIDS clinic turned to Zambia for a model of increasing the number of patients who showed up for treatment. Based on early successes, they are continuing under the project name “Zambama”.
2. FINANCIAL SERVICES: DOCOMO to Launch Mobile Remittance Service, NTT DOCOMO press release, 2 Jul 2009. Later this month Japan’s DOCOMO will enable individual subscribers to use their mobile phone to remit money to other subscribers. Such a branchless banking/financial remittance service is certainly prompted by Safaricom’s M-PESA service from Kenya.
3.  CLEAN TECH: Worldchanging Interview: Shawn Frayne, 2 Jul 2009. The interview is about wind technology, but touches on broader issues related to South-North innovation flow. Frayne thinks that “the constraints of the developing world can provide the necessary inspiration to make significant technological leaps that can benefit the Global South and Global North simultaneously”.

There are various other examples from the last several years suggesting a growing trend in countries from the North learning from the South. Here are examples just around financial services for the poor:

• Opportunity NYC was the first conditional cash transfer (CCT) program in the U.S., based on the Oportunidades program developed in Mexico.
  
• Less than one month ago international development micro-lender Kiva launched a pilot program in the U.S.
• Grameen Bank supports microcredit in places like Norway

Add to that the various management principles we’ve learned from the Aravind Eye Care System and Mumbai’s dabbawallas. Extending the argument presented by Fast Company, these examples show that South-North innovation transfer doesn’t have to be focused on corporations.

While it’s enticing to think about mining untapped innovation potential in the South for the benefit of the North, the real potential is much broader. Innovation can (and does) flow in all directions, not just South-North, but also North-South, South-South, and within countries. The challenge is to learn from different ways of approaching the same problem. Or even similar problems: see how Kaiser-Permanente visited a flight school to reduce medication errors and how the NHS worked with Formula 1 team to improve ICU procedures.

Given this potential, the big, open question is this… How do we increase global sharing of ideas and models to spur innovation?

What can patients tell us about fixing US healthcare?

Atul Gawande's recent New Yorker article about the super-high costs of healthcare in McAllen, Texas has gotten lots of people talking. (If you haven't read it, you need to.) In the White House, President Obama made the article White House required reading, as reported by the New York Times:

President Obama recently summoned aides to the Oval Office to discuss a magazine article investigating why the border town of McAllen, Tex., was the country’s most expensive place for health care. The article became required reading in the White House, with Mr. Obama even citing it at a meeting last week with two dozen Democratic senators.

Data show that increased healthcare spending does not necessarily result in better health outcomes, and that the spending varies widely within the US. The Gawande article begins to answer the question of why this is the case, but there is a counterpoint (also from the NYTimes):

In his blog last month, Mr. [Peter] Orszag wrote, “The higher-cost areas and hospitals don’t generate better outcomes than the lower-cost ones.” But other researchers and politicians are not so sure. They say it would be a mistake to cut or cap Medicare payments without knowing why spending in some places far exceeds the national average.

What's as interesting about Gawande's article as the story is the fact that the national discussion has been altered by a quick case study of a single town in Texas. (Aside: this is why extreme case sampling is so valuable.) What else can we learn by studying individual systems, sitting down with real providers, and talking to actual patients?

This was on my mind yesterday when I was waiting for a San Francisco BART train in Oakland. A woman in her late 40s was standing near me talking to a much younger woman about her experiences with safety-net hospitals. The loud-enough-to-be-public monologue, roughly captured:

They brought the x-ray machine to me this time. I told the people from Social Services, "There's no way I can pay for all this". The doctor came and told me it was a pulled muscle, and to go home, elevate it, and rest. I did just as the doctor said and four days later - four days - I got a call saying "We made a mistake". Then he said "They made a mistake". I went to Highland - no Summit - and they showed me two x-rays side-by-side. In the last one my bone was out of its socket and my kneecap was broken in two places. I was in rehab for 12 months!

Themes relevant to the current discussion: cost of care, role of technology, quality of care, trust in providers.

This is stuff Aman has been thinking about for some time, so I expect him to write about it soon.

Posts from Global Health Council 2009 (GHC36)

I've been quiet here for the last two weeks because I was blogging - and not cross-posting - at the Global Health Ideas blog from the Global Health Council's 2009 meeting in Washington, DC. We should have a final synthesis up over at worldchanging.com early next week. For now, here's a link to our team's posts from the conference itself, newest to oldest:

• Magic bullets & usability for postpartum hemorrhaging
• Trust & social desirability in m-health
• No such thing as “HIV in Africa” (Hans Rosling plenary)
• Discovering new strategies using proven [mHealth] technologies
• Vouchers work, but there will be challenges (voucher-based health programs)
• Where’s the rest of the mother? ("low-tech" solutions for improving child health)
• Harnessing all facets of the private sector
• Blogging the Global Health Council (GHC36): Music to the ears

And here's the Twitter search over hashtag #GHC36.

Linking clinic design to health outcomes

Cross-posted from the Global Health Ideas blog:

In October 2007 I was working in a place called Suhbaatar, a province in the flat and often dusty steppes of eastern Mongolia named after the hero of the 1921 revolution.  The primary activity of this trip was to hang out with community health workers in different sums (counties), a few days in each place, in order to better understand the role information played in their provision of services. The last sum I visited normally has about 4000 people, largely pastoralist nomads, living across an area 1.5 times the size of Rhode Island, with roughly half of them concentrated at the sum center during the fall months. A rough spring for the local pastures meant that many of these 4000 had left on otor, pasturing livestock up to 300km away, making it downright desolate.

On my third day in this sum, I asked the doctor managing the local clinic for a tour of the new clinic being built across the street.  GTZ and Lux-Development had both been here recently on health infrastructure projects, but this time the money was coming from the Mongolian government.  The doctor, a nurse practitioner, and I walked across the street where we met the foreman, a man who had come here from the capital Ulaanbaatar (photo).  Though the work crew was already working on the roof – the construction had started two months earlier – I was surprised to hear the doctor, who had worked here for more than 10 years, asking some critical questions about the layout of the new hospital. After several minutes of interrogation, the exasperated foreman claimed this hospital was the same design as one being completed in another sum. What the doctor knew and the foreman didn’t was that I had just visited that sum.  “Is this true?” the doctor asked me. “Does it have the same number of beds?” “Will our hospital be as big?” “No” was the answer on all counts. In consultation with the nurse, the doctor quickly realized this new hospital wouldn’t provide enough space to meet their patient demands.  So they would have to keep parts of the old hospital working to meet their needs.  So much for the touted energy efficiency of the new vakuum sunh (double-paned windows). This was the result of a top-down approach to hospital design.

Earlier this week the New York Times reported on how health outcomes are driving hospital design in U.S. settings (thanks Dr. Marwah for the article pointer):

In many new hospitals and pavilions … semiprivate rooms have vanished. Single-patient rooms are now viewed as an important element of high-quality health care. The benefits of the single room emerged through evidence-based hospital design, a new field that guides health care construction. More than 1,500 studies have examined ways that design can reduce medical errors, infections and falls — and relieve patient stress.

The idea is simple: change the design of the physical environment to reflect the needs of the people in the system - patients, visitors, administrators, caregivers, insurers - with an eye towards improving health outcomes. There are opportunities both for new construction, but also for retrofits. And the solutions are often simple. From the Times article, Princeton’s University Medical Center is installing larger windows “because studies suggest that natural light can reduce depression and that scenes of nature can reduce reported levels of pain”. From a 2007 SFGate article, Kaiser-Permanente is changing the color of the paint on the walls “to cheery spring shades of pale blue, yellow and green” in an effort to be more patient-focused.

All good and well, but what do systems with limited resources have to take from this approach? Quite a bit it seems…

As an example, consider the recent PLoS study from Peru (Escombe et al., 2007) that showed how natural ventilation - an low-cost alternative to negative-pressure isolation rooms - could be used to reduce intrahospital transmission rates of tuberculosis. The recommendation of the study? Open the doors and windows: “Even at the recommended ventilation rate, the calculated risk of airborne contagion was greater in these mechanically ventilated rooms [in modern facilities built 1970-1990] than in naturally ventilated rooms with open windows and doors [in older facilities built pre-1950]“.

As this research shows there are plenty of opportunities to change the way we work within existing facilities to improve outcomes. And there are plenty of opportunities with systems that are renovating and building new hospitals and clinics. A couple current examples: (1) the Millennium Challenge Corporation is renovating 150 health centers in Lesotho; (2) the Asian Development Bank is building 17 new clinics and renovating 7 facilities, including 3 provincial hospitals as part of the Third Health Sector Development Project in Mongolia (PDF).

The human-centered approach can improve health outcomes with simple innovations derived from a better understanding of the needs of a facility’s users. The open question is whether we’ll take advantage of such an approach or whether - in the words of   Roger Ulrich from Texas A&M’s Center for Health Systems and Design - we’ll simply “pay lip service to the evidence”.

New global health blog (globalhealthideas.org)

As many of you know I've been a contributor to the Technology, Health & Development blog over the last few years. We've recently moved off WordPress to a more permanent home. This makes the old site obsolete, although it will stay up. The same set of folks talking about the same sets of issues - a collective of research scholars and practitioners examining global health solutions with a focus on innovation and technology.

I'm cross-posting Aman's announcement here:

As some of you have noticed the Technology, Health and Development blog (THD Blog) formerly hosted at http://thdblog.wordpress.com has moved and changed names to this current site - Global Health Ideas (http:/globalhealthideas.org). Partly because of increased attention and scope we decided it was time for a more permanent home that would also allow us to do more. We are still going to be blogging about global health solutions, innovative projects and the use of technology and you can continue to reach any of us at thdblog AT gmail DOT com. All of our old posts will remain on the old site  and also can be found on this site. Please bear with us over the coming weeks as we sort through various bugs and coding errors.

You can subscribe to our blog feed from the following link: http://globalhealthideas.org/?feed=rss

And for those on twitter you can find Jaspal at: http://twitter.com/jaspaldesign

Also note that we will be live blogging from the Global Health Council's annual conference in DC 26-30 May. On Twitter we'll be at: @jaspaldesign, #ghc36 (the hashtag that the Global Health Council has endorsed).

Gahain tomuu - swine flu awareness for Mongol Bay community

Had lunch yesterday with Gerelmaa Bataa of Asian Health Services and Street Level Health to talk about her outreach work with the Mongolian Bay Area community, a group concentrated in Oakland, Alameda, and Albany. One of the questions I had was how she was trying to keep the community informed about swine flu (aka H1N1 aka Gahain tomuu). In addition to posting on a website frequented by Mongolian immigrants, she's posting flyers in apartment buildings with high density of Mongolians, talking to people seeking health services, and handing out these info sheets - same info as the flyers just smaller. The title reads: "Let's prevent the spread of swine flu".

Dry gin, wet soap & focus groups

A couple weeks ago a friend invited us to help her with a take-home activity she was assigned in advance of a focus group that she was doing for some extra cash. A UK-based firm had been contracted by a company that makes one of the products pictured above to understand how they might reposition the product. [Hint: not the one that is useful for combating ring-around-the collar.] This photograph was my main contribution to the activity since the one reminded me of the other.

As design researchers we constantly focus on empathy, but during this exercise I began to wonder how much we really empathize with the customer/user/client in their role as study participant. During the hour on the roof, there was quite a bit of rich interaction and discussion about the product - some positive, some negative, some tangential, but probably all useful. Our friend had been given a thick packet of questions to guide us through the activity - she was supposed to write answers to the questions by hand and was "free" to take photographs. More than one person mentioned that the questions seemed repetitive. It seems much of that rich social interaction was lost in the process of burdensome transcription, in part because of the quantity and quality of the questions. How much would that hour with us (live or by video or audio recording) have been worth to the client?

I talked to that friend again yesterday about the focus group itself. The research firm used it as an opportunity to test out new product concepts. At one point they brought a bottle of something green and she said, in reference to the above photograph: "My friend doesn't want to drink anything that looks like dish soap". The bottle was quickly whisked away. Another one of her observations: the focus group - like other focus groups she has participated in previously - was dominated by 1-2 people. An observation that suggests we should be more careful about how we use focus groups. It would be unfair to generalize about focus groups based on this sample, but it does suggest that we need to ensure that we appreciate the importance of good facilitation.

The Global Downturn Lands With a Zud on Mongolia's Nomads (WSJ)

The Global Downturn Lands With a Zud on Mongolia's Nomads, from the Wall Street Journal (thanks Sara for the pointer). The story is about herders defaulting on loans due to decreased demand for cashmere in the midst of the global economic crisis. The title is a reference to "financial zud", a rather stark metaphor that compares the current situation to an extremely harsh winter in which many livestock die: zud on Wikipedia, the 1999/2000 zud as covered by BBC. The article focuses on the story of an individual herder in Tsogt sum in Govi Altai who has lost his animals to the bank. The piece includes a video (embedded below) and a photo slideshow - much more coverage than Mongolia typically gets. The photo above is from the slideshow and shows a bagiin emch at work. Given my interest in bagiin emch, this is notable - certainly the first time a bagiin emch has gotten his or her photo in the Journal. To see the full version of the above, see photo 7 in the slideshow (some excellent images in this set). For even more, see the photographer Josh Chin's Mongolia set on Flickr.

More research on bagiin emch (from HSUM Mongolia)

An MPH student from the Health Sciences of University of Mongolia recently contacted me on the recommendation of one of her faculty from the Department of Social Sciences. The reason? She was doing research on bagiin emch - aka bag feldshers - and I was one of the few people who had done any research on this group. Exciting stuff for me. With Khostuya's permission, I am posting the English language abstract of her Master's thesis here, along with keywords in English and Mongolian:

WORKLOAD AND JOB SATISFACTION OF BAG FELDSHERS

B.Khostuya, Kh.Damdinjav
School of Public Health, HSUM (Mongolia)

Purpose: 
To determine the workload and job satisfaction of Mongolian bag feldshers (bagiin baga emch), to summarize the results, and to develop recommendations for improvement.

Methods:
The study involved in total 88 bag feldshers (2 soums from all 21 provinces for a total of 42 soums; 3 bag feldshers from 4 of these soums and 2 bag feldshers from the remaining 38). We conducted the research using both quantitative and qualitative methods. Collected data were analyzed using SPSS 12.0. We registered working hours and activity by direct observation. Upon analysis, we clarified basic and additional work structure through document analysis and interviews.

Conclusions: 
The workload of bag feldshers varies by season, week, and day.  It is not possible to determine their workload and job satisfaction using timing methods. Medical services are limited because 40.9% of bag feldshers involved in our study live at the soum center. The workload of those bag feldshers living at the soum center is less than those living in the countryside. Although bag feldshers tend to be satisfied with their job, there are persistent issues with support for social services.

Keywords: Bagiin baga emch, work conditions, workload, satisfaction, working environment

Түлхүүр үг: Багийн бага эмч, ажлын нөхцөл, ажлын ачаалал, сэтгэл ханамж, ажиллах орчин

Dissertation talk on 21-Apr

I'll be giving my dissertation talk tomorrow in Berkeley:

Title: Serial Hanging Out in Mongolia: Information, Design & Global Health

Speaker: Jaspal S. Sandhu, University of California, Berkeley

Adviser: Professor Alice M. Agogino

Date: Tuesday, April 21, 2009

Time: 12:00-1:00PM

Location: Berkeley Institute of Design (BiD), 360 Hearst Memorial Mining 

Building (directions)

ABSTRACT

Many global health disparities persist not from a lack of technical solutions, but from an inability to effectively implement existing measures. While financing and human resources are critical concerns, so too is the need to better understand and adapt to the people who execute and benefit from these solutions. There is a significant opportunity here for applied ethnographic methods from design (design research) to examine the norms, knowledge, and needs of these individuals and groups. Despite interest in such an approach by organizations such as PATH, The World Bank, and the Bill and Melinda Gates Foundation, we still have a limited understanding of design research methods in the context of global health and development.

This dissertation aims to improve our understanding of these methods. It is a case study of a design research project examining the information management practices of “bagiin emch”, nomadic health workers in rural Mongolia. The design research was conducted between June 2006 and August 2008 in Mongolia in cooperation with the Ministry of Health and the Asian Development Bank’s Second Health Sector Development Program (HSDP-2). Although study participants included bagiin emch who received handheld computers from HSDP-2, the emphasis of this research was not on technology, but on innovation - the development and adoption of new information management solutions.

The primary field method was serial hanging out: multi-day, design-oriented participant observation. Serial hanging out is a novel approach to design research well suited to global health, so the contextual examination of the method is a primary contribution of this dissertation. The dissertation also operationalizes theoretical saturation for participant observation, providing empirically-based guidance for sample sizes, as had only been done for semi-structured interviews (reproductive health research) and focus groups (market research) prior to this study. This dissertation demonstrates how these methods achieve a richer understanding of people and phenomena, and how that is relevant to improving population health. At the same time, the dissertation explores how to use these methods most effectively, including an examination of design research capacity-building.