83% of Rwanda’s 12,000,000 population lives rurally outside of its main capital of Kigali. The Rwandan universal healthcare system was entirely built from the ground up after the Rwandan genocide as a way to address the health needs of all its citizens equally. This system, which is free to citizens, can successfully deliver quality healthcare at roughly $2 per person per year. It addresses the more immediate needs of the country’s rural citizens via an extensive network of healthcare centers and local community healthcare workers CHWs located in villages. Services offered at these clinics range from antenatal care, administering child nutrition programs, and diagnosing acute illnesses (including COVID-19 and malaria). E-Heza is a tablet application used by CHWs in some of these health clinics. The ultimate goals of the CHWs are to diagnose, provide routine and simple care, and ultimately refer complex patients to the better equipped regional health centers. E-Heza’s primary role is to document patient care, support decision making, and lastly replace a paper-based system that required significant cognitive load on CHW and health center staff. In this talk we’ll be addressing several topics: How do we adapt the participatory design process when we’re unable to have direct access with the users of our designs? How do we build relationships with local healthcare team members when we have to design across geographical and cultural lines? How does the local team aid the work and send feedback back up the chain to affect design changes? What does designing for a one-to-many healthcare interaction look like in terms of processing large segments of people and enabling non-clinical staff to make accurate medical decisions? Are there parallel challenges to designing for American healthcare systems and those of rural Rwanda and how might they be affected by assumptions of class and race?

1. DESIGNING HEALTH
SYSTEMS FOR RURAL
COMMUNITIES IN RWANDA
UX Camp Chicago 10/17/2020
Tricia Okin

2. Hello, I’m Tricia Okin
As a lead user experience designer and
service designer, and design strategist I use
design thinking for the public good and the
good of your business. This can take the form
of facilitating design thinking workshops that
include communities and stakeholders
holistically working together.
@papercutny

3. Problem: Administering Healthcare In Rural Environments
The E-Heza Tablet Application
Innovation: How Vs. What You Design
Challenges
Wrap Up
AGENDA
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4. HOW MIGHT WE SERVE
THE HEALTHCARE NEEDS
OF PEOPLE IN DISTANT
RURAL AREAS?

5. of Rwandans
live in rural
villages
83%
(Total Population: 12,400,000)

6. Universal Healthcare in Rwanda is
designed as a national system & is
extremely successful.
BUT without input from hyper-local
branches that need customization
to address the needs of their
clientèle

7. Healthcare workers
feel powerless being
stuck between
national expectations
and metrics & the
needs of their local
patients or facilities
users.

8. HOWEVER…

9. Rwanda is a small nation doing
everything that people think they're
doing in a 2-week sprint - innovating
and iterating in the service of these
small rural communities.
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10. They're testing and creating tools from
the ground up in terms of the process,
feedback, and design to create tools
everyone can use.
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11. TIP GLOBAL HEALTH
Wanted to serve medically underserved
communities to help create sustainable
healthcare opportunities and initiatives
(Formerly The Ihangane Project)
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Programs include: FBF program (fortified
blended food); HIV/AIDS monitoring;
malaria; ante-natal care & more

13. We use a participatory design model.
TIP expanded the scope of the application
to more than they thought it would be to
give workers comfort in making COVID diagnoses
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14. Lack of data access to connect
devices
Delayed or unreliable data
from central EMRs
RURAL HEALTHCARE CHALLENGES:
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15. Seeing 150 — 200 patients
per day for various reasons
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16. Paper-based systems where
CHWs had to complete up to 17
paper ledgers for each patient
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17. Cognitive load on the CHWs and
delays in care to the patients
who had walked miles or took
expensive transport to get there
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18. THE E-HEZA TABLET
APPLICATION

19. RWANDAN HEALTHCARE SYSTEM
District
Hospital
Health Centers
Catchment Area
Catchment Area
CHWs
Village
Central
Level

20. RWANDAN HEALTHCARE SYSTEM
District
Hospital
Health Centers
Catchment Area
Catchment Area
CHWs
Village
Data is Accessible to Users based on User Type and Catchment Area
Data collected at lower ‘level’ will be easily visible
to all who have access at ‘higher’ levels.Central
Level

21. E-HEZA TABLET
APPLICATION
It’s a digital data solution NOT
an EMR system
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Works based on the national
database EMRs such as OpenMRS
and HMIS
+ Eases physical and mental
workloads for the local teams
+ Works with data offline & can sync later
after connections are reestablished

22. GROUP HEALTH
INTERACTIONS
Built to natively handle 1-to-
many healthcare interactions
for Ante-natal care
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Next steps are designing and
building out the Acute Illness
modules for group encounters

23. ACUTE ILLNESS
DIAGNOSIS
Diagnosis ranging from malaria
to gastroenteritis and COVID-19
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24. ACUTE ILLNESS
DIAGNOSIS
Essentially it’s a decision-ing
engine for “lower skilled”
workers to make informed
medical care decisions
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Diagnosis ranging from malaria
to gastroenteritis and COVID-19
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25. ACUTE ILLNESS
DIAGNOSIS
Captures symptoms, travel
history, medication, and
isolating the patient
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26. ACUTE ILLNESS
DIAGNOSIS
+ Provides guidance to CHWs to
escalate up to the health
centers immediately
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30. WORKING TOGETHER:
INNOVATION & CHALLENGES

31. INNOVATION IN WHAT YOU DESIGN FOR
+ US: encounter-based,
1 doctor, nurse, etc. to
1 patient

32. Urgent Care: appointment-based, but
focused on short appointments for
routine stuff.
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33. Drive-up Testing and Flu Clinics:
might be scheduled, but aren't traditional
appointments; you book a time slot, get
the test or administration, and you go.
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34. INNOVATION IN WHAT YOU DESIGN FOR
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Value-based care: healthcare organizations being paid/
reimbursed to care for the patient's whole health, or for a
population of people.
Reporting on trends across a patient panel
Determining whether patients are due for care
Ensuring that standard care for chronic conditions is
provided, or that patients are being diligent about their
wellness visits
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35. INNOVATION IN WHAT YOU DESIGN FOR
+ RWANDA: 1 CHW to
several patients,
triaging to either
quick treatment or
sending to a health
center

36. Multiple encounters/patients at one time+

37. Rapid clinical decision-making for people
who don't have a ton of clinical expertise
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38. INNOVATION IN WHAT YOU DESIGN FOR
Ability to quickly flag when a patient needs more
experienced/involved treatment, and connect them with a
health center that can do that work.
Designing for the health and concerns of the CHWs as well
of the patients. How do we reinforce the safety of the CHWs
while giving them a sufficient scaffolding to educate their
patients through the next steps? (Anticipatory Guidance)
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39. INNOVATION IN HOW YOU DESIGN
+ Creating a 2-part perspective in the user test:
Designing research and user testing for both the
intermediary clinical team at the centers who are
administering the user tests directly to the CHWs.

40. Democratizing user research and facilitation:
working together with the local team to draft
questions and then they translate into
contextual Kinyarwanda.
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41. TRAINING & USER TESTING W/CHWs
+ How do CHWs convey the concepts to the patients?
How would they talk to a patient about isolating them or
contacting the health center?
Do the symptoms and health conditions in the app match
what they see?
+ Writing user tests to focus not on the procedure and
mechanics but the community interaction.

42. METHODOLOGY CHALLENGES
+ A new way of working: I had to reconcile not testing
directly with users of the application — this means I had
to build rapport with the local team to test with CHWs

43. Medical staff training the CHWs can
function as user tests because the
CHWs actively give feedback which
resulted in design / app iterations

44. METHODOLOGY CHALLENGES
Working remotely with a healthcare team in Rwanda,
dev team in Middle East, PM in Western Europe and
design/admin team across the US
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45. CULTURAL CHALLENGES
+ Is designing for group healthcare encounters in rural areas
the same in both Rwanda and the United States? Both lack
resources and infrastructure.
+ What biases would I bring to the design process as someone
from the global north while designing for the global south?

46. WRAPPING UP
ANY QUESTIONS?

47. THANK YOU!
FIND ME AT:
tricia@papercutny.comEmail:
https://www.triciaokin.comSite:
https://www.linkedin.com/in/triciaokin/LinkedIn:
https://twitter.com/papercutnyTwitter: