Back in the day, Carla and I were neighbours and classmates at UNC SPH. Carla since went on to work for PSI in Haiti and Papua New Guinea and most recently as an IDEO fellow in their San Francisco office. Happily, she agreed to be interviewed for this blog. No-one is better positioned to describe the benefit of design thinking for public health…
How do you nurture innovative thinking in a bureaucracy?
I wish I had the answer! I don’t think anyone has figured out whether the best approach is to promote innovation systemically or to have a sub-group acting as an incubator for new ideas. Some large organisations, like the Grameen Foundation, have a human-centred designer-in residence to promote design thinking across their organization. Others, like UNICEF, have set up Innovation Labs all over the world. Innovative thinking will not usually happen in the context of business as usual work, as it requires a different and disruptive mindset. How often have you discussed ideas in a group and everyone thinks of every possible way an idea could fail? In fact, it’s one way people are accustomed to demonstrate their intelligence and experience – think of all the ways the proposed idea is naïve or unrealistic. Design thinking requires a totally different and much harder mindset- “what would it take for this idea to succeed?” In a bureaucracy, what would it take for people to feel more valued for thinking this way than in being critical? This requires a big cultural shift away from “expertise”. At IDEO.org, our credentials, our degrees, our years of experience, or the countries we worked in - none of that mattered. What matters is how you can contribute to the conversation.
The first step to looking for new ideas is to step outside. Right now. Why posit what could or could not work when you can step outside and ask someone on the street?
The design thinking approach seems like it could be resource-intensive, time consuming and expensive for tight NGO budgets. Is this your experience? Is there a way to make it cheaper?
Whether it is resource intensive or not depends on how it is utilized within the organization. When we think about how to deploy “design thinking”, it can be better to think about it as a mindset and an approach. A mindset doesn’t necessarily cost anything. The methodology that IDEO.org developed to work through creative problem-solving is called “human-centric design.”
It’s not really revolutionary or radical. Its aim to work towards solutions that put the priorities and desires of the end user first. This sounds simple, and it is, but often when we are presented with a problem, our first impulse is to jump to the solution. Without first establishing an deep understanding of the end user and being inspired by fresh ideas these solutions are more likely to reflect our own priorities and desires than those of the end users, no?
One of the ways in which “design thinking” can save resources is to test our assumptions by using prototypes. A prototype is anything that can test the assumptions of a concept. It does not have to look like the final solution and it helps if it is employed early, before you get too emotionally attached to an idea. For example, if your assumption is that parents are not immunizing their children because the health posts are too far away, then set up a temporary post for a couple of days in a more convenient location to see what response you get. Prototypes are meant to provoke responses – not be the solution.
Designers are good at prototyping quickly, and the prototype is not necessarily a facsimile of what the solution would be, you might just prototype for one component of the problem to test different assumptions, and answer questions. The prototypes are not meant to give you representative data, but just lets you see how things might work before you are emotionally invested in the idea. It forces you to be very clear about what your assumptions are.
Where do you think the untapped potential of design thinking lies?
One of the things I like about the human centred design approach is to speak to extreme users. For example, you might go and speak to a doctor who owns a sophisticated clinic, and then a midwife who runs a small clinic in a low-resource setting. This gives more relief, contrast and visibility to what you see.
Can you tell me about a “well-designed” public health solution you worked on?
One of the public health projects I worked on at IDEO.org was with a social enterprise who run a latrine franchise in a slum in Nairobi. The business model is to generate income for the latrine owner, who charges residents for use of the latrine, while the social enterprise generates a profit from processing the solid waste from the latrines into fertilizer.
The problem was a lot of latrines had a very low average number of users, and it wasn’t clear why since the franchised latrines were by far the cleanest in the area and the cost was average. We spent a lot of time observing latrine use, using latrines, and speaking to people about their latrine use. One important insight was how residents defined proximity. It had less to do with which latrine took less time to walk to than which was conveniently located along a route the resident already planned to take – to buy milk or catch a matatu. So our definition of proximity had to be adjusted.
The other factor associated with successful latrines was the latrine attendant. Attendants who owned the latrines were more likely to allow their customers to use the latrine now and pay later in the day when they had money. This built loyalty and allowed customers to use the latrine when they needed to, not just when they had money.
It might seem like these answers are so simple – they are! And yet we are sometimes in so much of a hurry to find a solution that we forget to put ourselves in the shoes of our users. This is where having a methodology, like human-centred design, can help.
In public health it’s often said that we already know what the solutions are, the problem is implementation. In this instance, how can design thinking help?
Let’s think of an example – suppose we know that misoprostal is the best way to prevent post partum haemhorrage and is part of official protocol for birth attendants. But suppose despite its effectiveness, it is not being used. Do we know why not? In this example, we think we have the solution to a problem, but it’s not taking hold.
Design thinking can help understand the system and context in which the problem is persisting. With a user centred design methodology, you would spend time with the practitioner, the pharmacist and the people running the supply chain to try and understand what the barriers, challenges and opportunities might be. Observing every part of the system could help us see the subtle issues that are not immediately visible, such as cultural perspectives on bleeding, the status of the provider, the perceived effect of the drug (the drug doesn’t take effect in a very visible and immediate way, like a pain-killer does).
What kinds of public health challenges are best suited to design thinking?
I think design thinking can make a huge contribution to three areas; products, services and experiences.
Products: An example of a great product is Sayana Press. This is a single Depo Provera dose in a disposable needle and syringe, it can be delivered by community health workers with minimal training. It allows you to expand the reach of DepoProvera beyond facilities and medical staff, and into communities.
Services: Design thinking can help you envision what a good service would look like to an end-user without making assumptions about what that would be. Would they like family planning services brought to their door? Or, would that be really embarrassing because all their family members are around?
And post-abortion care – does it make business sense for providers to provide this service? In this case, is intimacy with the community a barrier or a bonus?
Experience: When male circumcision was first adopted in Africa for adult men, there was a lot of nervousness about receiving the service. At one franchise of clinics, they adopted an approach of total affirmation of the service. The guard, the receptionist, the nurse and the doctor would all congratulate clients, and tell them well-done for getting this service, they were doing a great thing for themselves and for the country. This empathy shaped a more concrete and consistent service experience for clients.
So, quickly, what is the value add in design thinking for public health?
It helps you:
Gather insights from the end user before jumping to a solution
Test ideas and assumptions quickly before settling on a solution
Use inspiration and insights to challenge the status quo
Thanks to Carla for her time and thoughts! For design thinking and innovation resources, click here.