Roberta Tassi, frog's Senior Design Researcher in Milan, shares her thoughts on system thinking for large scale impact.

1. System thinking for large scale impact
ROBERTA TASSI
WIAD 2014 15 febbraio
DESIGN FOR
EVERYDAY LIFE

2. sys·tem
a set of connected things or parts
forming a complex whole.
For example a set of things working together as parts of a mechanism
or an interconnecting network.

3. understanding
#empathy #data #patterns

4. modeling
#synthesis #structure #visualization

5. translating
#guide #shape #link

7. the vast majority of the seven
million children who die every year
never see a doctor

9. community health workers
are the “last mile” in healthcare and
one of the the biggest untapped
resources in global health.

11. how to design a comprehensive
and systemic solution to
empower Community Health
Workers at a global scale?

12. design research
understanding CHW aspirations,
workflow and needs
We relied on a Human-Centered Design process to shape solutions for CHWs
that are based on a deep understanding of their real-world needs.
01

13. UGANDA
Before CHWs, having medicines
to treat malaria available right in
the village was a daydream.
CHW SUPERVISOR
4 DISTRICTS, 37 INTERVIEWS
Backpack Plus Design Research

14. Backpack Plus Design Research

15. The main challenge is sensitizing
people to look for health services
to timely treat their illnesses.
CHW (ASC) SENEGAL
3 DISTRICTS, 26 INTERVIEWS
Backpack Plus Design Research

16. Backpack Plus Design Research

17. system thinking
mapping and modeling
CHW programs
The Backpack PLUS framework is a CHW-centric model that identifies
all the essential physical, digital and service-level components required
to empower and activate CHWs along their journey.
02

18. CARE
COMMUNITY HEALTH SYSTEM
SERVICES
TOOLS
CHW
TRUST
CARE
SUPPORT
REPORT
CARE
Backpack Plus Framework

19. INDIVIDUALCOMMUNITY
ASSESS
& TREAT
EDUCATE
RESPECT
TRUST
SUPERVISOR HEALTH CENTER DISTRICT
SUPPLIES
REPORT
COACH
SUPPORT
REPORT
REPORT
INSTRUCT
SUPPLIER
TRAINING SERVICE DELIVERY REVIEWING RESUPPLY REWARDINGRECRUITING UPGRADING
CHW
DIAGNOSTICS TOOLS ENABLERSCOMMODITIES
ASSESS TREAT EDUCATE REPORT
Backpack Plus Framework

20. Backpack Plus Framework

21. ADVANCED MODULES
BASIC SET
DIAGNOSTICSCOMMODITIES TOOLS ENABLERS
ACT AMOXICILLIN
CHLORHEXIDINE
PARACETAMOL
RDT
RESPIRATORY
TIMER
MUAC
ORS & ZINC
GLOVES
ALCOHOL PADS ALCOHOL
SCISSORS
SOAP
BANDAGES
SYRINGE
TRASH BIN NOTEBOOKTHERMOMETER
TRANSPORTATION
(bike, motorbike,...)
UNIFORM
HOUSE
SIGNAGE
ADVANCED ED.
MATERIALS
FEEEDBACK
SCORECARD
HOUSEHOLD
REGISTER
HEALTH PROMOTION
MESSAGES
MISOPROSTOL IPT
JOB AIDS ED. MATERIALS
VISIT REGISTERREFERRAL FORMS
STOCK REGISTER
RAIN BOOTS RAIN COAT
TORCH, LIGHTPENCILS, PENS
SOLAR CHARGER MOBILE PHONE
VITAMIN A
mother
VITAMIN A
children
PILLS CONDOMS PREGNANCY TEST
INJECTABLE
RUTF SCALE
HIV TEST
DEWORMING
(Albendazole)
MAMA KIT
1|PREGNANCY&NEWBORNCARE2|FAMILYPLANNING3|MALNUTRITION4|HIV5,6,7|ADVANCEDSETS8|MAMAKITBASICSET
TOOLS
JOB AIDS ED. MATERIALS
VISIT REGISTERREFERRAL FORMS
STOCK REGISTER
Backpack Plus Framework

22. ACTORS INVOLVED
DESIGN PRINCIPLES
SERVICE ELEMENTS
ON DEMAND
RESUPPLY (supervisor)
Ensure continuity by
selecting people who are
long-term members of
the community
(resident, married).
Leverage existing
influential roles that are
already present in the
community.
Manage age limits (min
but also max age).
Embrace flexibility to
adapt the criteria to
specific regions (i.e.
nomadic areas,
low-literacy,...).
SELECTION
CRITERIA
PUBLIC
ANNOUNCEMENTS
REGULAR
REFRESHER
CHW
LIST
Define
reference
recruiting
criteria
RECRUITING TRAINING SERVICE DELIVERY REVIEWING RESUPPLY REWARDING UPGRADING
Create modular training
plans to enable
incremental learning
and differentiate
competences.
Teach fundamentals of
time/budget
management.
Provide analog and
mHealth services that
can be access by CHWs
also at the end of the
training period.
Create a moment at the
end of each training
session to certify and/or
celebrate the new
competences aquired by
CHWs.
Set up routine refresher
training sessions to
ensure a continuous
learning experience.
Support a
continuous
learning
process
Provide standard
protocols with reference
materials that guide the
assessment through a
series of steps.
Create strong
consistency and
cross-references across
job aids, diagnostics,
commodities and
informational materials.
Include visuals that help
understanding and
sharing the process also
with the patients.
Improve
guidance
through
integrated
tools
Provide standard
instructions for dosages
with supporting
reference materials.
Create strong
consistency and
cross-references across
job aids, diagnostics,
commodities and
information.
Support referral at a
system level (i.e.
referred patients are
given priority at the
clinic).
Strenghten follow-up
visits through protocols
and reminders.
Provide
clear
instructions
& follow-up
Facilitate education
processes through rich
media (visuals, audio,
video).
Optimize content and
materials to address
different situations (1:1,
households, group
sessions).
Stimulate an active
engagement of the
community.
Provide
tools to
facilitate
education
Facilitate consistent
data tracking through
clear recording
standards and
protocols.
Enable data sharing
across different
stakeholders by
armonizing tools and
optimizing transmission
of information.
Enable data mining by
facilitating aggregation
of information across
tools.
Give value to the
collected information by
giving it back to CHWs
and their communities.
Improve
data
collection
and mining
Establish clear roles of a
supervisor and
relationship to the CHW
(e.g. how often they see
each other).
Ensure a continuous
support and supervision
through meetings at
defined intervals (e.g.
weekly meeting).
Include role-modeling
through joint visits with
supervisors.
Include spot checks of
the supervisor with the
community.
Enable the collection of
a clear basic set of data
that supports the
supervisor with
performance
management.
Enable the supervisor to
set real incentives in
case of good
performance.
Set clear
roles and
responsabil-
ities
Address restocking by
using data to make
effective forecasts.
Maximize resupply
efficiency by
communicating
availability of stocks.
Bring the supplies as
close as possible to
CHWs by leveraging
existing resources
(shops, private supply
chains, etc.).
Facilitate transportation
(either by
reimbursement or by
providing logistical
support).
Optimize
access and
system
efficiency
Enhance the community
perception of the role of
CHWs through branded
materials.
Give visibility to the
CHW-enabled outcomes
inside the community.
Celebrate
& reward
the work
of CHWs
Establish a clear career
path based on personal
inclinations and impact.
Provide incremental
training to enrich and
evolve competences.
Establish
a clear
career
path
SUPERVISOR
STANDARD
PROTOCOLS
REFERENCE
MATERIALS
VISIT
TRACKING
STOCK
TRACKING
HOUSEHOLD
TRACKING
BASIC MODULE
ON EDUCATION
SPECIAL MODULES
(e.g. RDT)
CHW
CERTIFICATION
BASIC MODULE
ON ICCM
REFERENCE
MATERIALS
MOBILIZATION FOR
SPECIAL EVENTS
BEHAVIOR CHANGE
DEMONSTRATIONS
STANDARD
PROTOCOLS
REFERRAL
PROTOCOLS
REFERRAL
TRACKING
REFERENCE
MATERIALS
ONE-TO-ONE
REVIEWS
SPORT PERFORMANCE
CHECK
GROUP
REVIEWS
‘LEAVE-BEHIND’
INSTRUCTIONS
EDUCATIONAL
GAMES
RESUPPLY BY
CONSUMPTION
ADDITIONAL
TRAINING MODULES
GRATIFICATION
BY BRANDED KIT
REIMBURSEMENTS
(e.g. TRANPORT)
INCENTIVES
THROUGH GADGETS
FACILITATION BY
BASIC ENABLERS
CARRIER
PATH
PERFORMANCE
BASED REPORT
ASSESS TREAT EDUCATE REPORT
BASICCOMPONENTSNENTSINDIVIDUALCOMMUNITYSUPERVISORCLINICDISTRICTSUPPLIERDESIGNPRINCIPLES
Establish clear roles of a
relationship to the CHW
(e.g. how often they see
Ensure a continuous
support and supervision
through meetings at
defined intervals (e.g.
Set clear
roles and
responsabil-
Address restocking by
using data to make
effective forecasts.
Maximize resupply
efficiency by
communicating
availability of stocks.
Bring the supplies as
close as possible to
CHWs by leveraging
Optimize
access and
system
efficiency
Enhance the community
perception of the role of
CHWs through branded
materials.
Give visibility to the
CHW-enabled outcomes
inside the community.
Celebrate
& reward
the work
of CHWs
Establish a clear career
path based on personal
inclinations and impact.
Provide incremental
training to enrich and
evolve competences.
Establish
a clear
career
path
Backpack Plus Framework

24. TRAINING SERVICE DELIVERY REVIEWING RESUPPLY REWARDINGRECRUITING UPGRADING
INDIVIDUALCOMMUNITY
CHP
SUPERVISOR SUPPLIERHEALTH CENTER
SUPPLIES
ASSESS
& TREAT
TRUST
REPORT
COACH
REPORT
DIAGNOSTICS TOOLS ENABLERSCOMMODITIES
SUPPORT
ASSESS TREAT EDUCATE REPORT
HEALTH RELATED GOODS
SERVICES
LG BRANCH
INDIVIDUAL CHWCOMMUNITY
SUPERVISOR
SUPPLIES
ENGAGE
INFORM
COACH
REPORT SUPPORT
REPORT
REPORT
SUPPORT
SUPPLIERHEALTH CENTER DISTRICT
MAPPING OTHER PROVIDERS
MAPPING OTHER USERS
MAPPING PRIVATE OPPORTUNITIES
Backpack Plus Framework

25. product and service design
from research insights to
holistic solutions
Starting from core CHW needs highlighted during field research we
identified opportunities to improve the quality of the solutions they are
provided. Integrating physical tools and mobile-enabled services into one
cohesive experience will positively impact community health outcomes.
03

26. Current tools and process meant to support
CHWs are fragmented, often affecting
effectiveness and undermining motivation.
“The job aid
is our Bible”
CHW (UGANDA)
Backpack Plus Research Insight

27. Backpack Plus Toolkit

28. From a disconnected
set of diagnostic tools
and medical
commodities to a
well-orchestrated
experience that
improves CHW
effectiveness.
Backpack Plus Toolkit

29. Storage and carrying solutions for tools and
commodities aren’t flexible enough and do not
support CHW workflows.
“The bag I was
given is big and
bulky, I never need
to carry that much.”
CHW (UGANDA)
Backpack Plus Research Insight

30. Backpack Plus Toolkit

31. From generic
storage and
carrying solutions
to a system
designed to easily
adapt to
evolving CHW
needs.
Backpack Plus Toolkit

32. Data that is currently generated by CHWs and
other actors in the system is not consistent and
seldom turned into useful information.
“The data
collected here
is always
incomplete.”
DISTRICT MANAGER (SENEGAL)
Backpack Plus Research Insight

33. From one-way data
flows to closed
and effective
feedback loops
that provide real-
time access to
essential
information.
Backpack Plus Toolkit

34. CHWs are asked to cover an ever-increasing
variety of health domains, not always properly
supported by training and adequate tools.
“New training
means that they
are investing
in us!”
CHW (SENEGAL)
Backpack Plus Research Insight

35. Backpack Plus Toolkit
From irregular
training sessions
to a continuous
learning model
that targets CHWs
but also accounts
for the need to
educate their
communities.

36. Current incentive programs -monetary or
otherwise- often fall short of being perceived as
making the difference in the lives of CHWs.
“These people
put in their own
money to do
their job!”
CLINICAL OFFICER (UGANDA)
Backpack Plus Research Insight

37. Backpack Plus Toolkit
From fragmented
incentive programs
to a clear
hierarchy of roles,
responsibilities,
benefits and
opportunities for
growth over time.

38. Fragmented or inefficient supply chains can result
in perceived lack of CHW support, and undermine
the level of trust they need to be effective.
“Why should I walk
to the clinic if then
they don’t have
medicines?”
CHW (SENEGAL)
Backpack Plus Research Insight

39. Backpack Plus Toolkit
From closed
ecosystems to
integrated public
and private
sector initiatives
aimed at better
supporting CHWs
and Supervisors.

40. Backpack Plus Toolkit

41. Backpack Plus Toolkit

42. Backpack Plus Toolkit

43. Backpack Plus Toolkit
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44. Backpack Plus Emblem

45. Backpack Plus Emblem

46. Backpack Plus System
Framework
A reference framework to
gather best practices,
assess gaps and align
partners to scale up existing
and future CHW initiatives.
Toolkit Emblem
A systemic set of physical
and digital tools to empower
CHWs and improve the
quality of the healthcare
services they provide.
A symbol for Backpack
PLUS that could be used by
the public health
community for advocacy
and large scale fundraising.

47. Backpack Plus What’s next

48. T h a n k s