Designing for global health - Royal Society of Medicine
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Designing for global health - Royal Society of Medicine
- 1. Thinking with design in global health Transforming access to diarrhoea treatment with design thinking – the ColaLife story Royal Society of Medicine 5-Dec-2018 Simon Berry Co-founder & CEO, ColaLife simon@colalife.org
- 2. Thinking with design in global health Transforming access to diarrhoea treatment with design thinking – the ColaLife story Where we started 2 Value chain thinking 4 The design process The public sector 6 1 Why design? Our idea 3 5
- 3. Thinking with design in global health Transforming access to diarrhoea treatment with design thinking – the ColaLife story Where we started Value chain thinking The design process The public sector Why design? Our idea 2 4 6 1 3 5
- 4. It is better to design on the basis of what you know people WANT rather than on what you think they NEED. Why design?
- 5. Thinking with design in global health Transforming access to diarrhoea treatment with design thinking – the ColaLife story Where we started Value chain thinking The design process The public sector Why design? Our idea 2 4 6 1 3 5
- 7. Diarrhoea 19%of infectious disease deaths Malaria 15%of infectious disease deaths AIDS 4% Source: Liu et al (2015) Global, regional, and national causes of child mortality in 2000–13, with projections to inform post-2015 priorities: an updated systematic analysis. The Lancet. 2nd biggest killer is diarrhoea.
- 9. The diarrhoea treatment that 90% don’t get ORS + zincOral Rehydration Salts
- 10. Where we started
- 11. Remote rural retail shop, Kalomo District, Zambia Drug store room, Tiriri Health Centre, Katine, Uganda Coke gets everywhere – medicines don’t
- 12. Thinking with design in global health Transforming access to diarrhoea treatment with design thinking – the ColaLife story Where we started Value chain thinking The design process The public sector Why design? Our idea 2 4 6 1 3 5
- 13. Our idea
- 14. Thinking with design in global health Transforming access to diarrhoea treatment with design thinking – the ColaLife story Where we started Value chain thinking The design process The public sector Why design? Our idea 2 4 6 1 3 5
- 16. Value chain thinking Distribution excellence Strong value chain Desirable, aspirational product
- 18. Thinking with design in global health Transforming access to diarrhoea treatment with design thinking – the ColaLife story Where we started Value chain thinking The design process The public sector Why design? Our idea 2 4 6 1 3 5
- 19. What we learnt Litre ORS sachets are too big Measuring water was an issue Willingness to pay Preferred branding The design process – finding out what people want
- 20. The product: Kit Yamoyo
- 21. Kit Yamoyo • Attractive Kit Yamoyo brand, design and benefits
- 22. Kit Yamoyo • Attractive • ORS sachets are 200ml Kit Yamoyo brand, design and benefits
- 23. Kit Yamoyo • Attractive • ORS sachets are 200ml • Packaging is also: – A measuring device for the water Kit Yamoyo brand, design and benefits
- 24. Kit Yamoyo • Attractive • ORS sachets are 200ml • Packaging is also: – A measuring device for the water – A mixing device Kit Yamoyo brand, design and benefits
- 25. Kit Yamoyo • Attractive • ORS sachets are 200ml • Packaging is also: – A measuring device for the water – A mixing device – A storage device (the soap tray is a lid) – A cup Kit Yamoyo brand, design and benefits
- 26. 60% Only 60% of carers mixed ORS correctly when given conventional litre sachets. 0 Suppliers sold ORS or Zinc in the private sector. <1% of children received the correct treatment for diarrhoea – ORS & Zinc 7.3km Average distance to ORS at clinics (1 L sachet only, no Zinc). >26k Kit Yamoyos sold into 2 remote rural areas in 1 year via existing market channels. 45% of children in trial areas received ORS/Zinc. Up from a baseline of <1%. 2.4km Distance to ORS/Zinc in the trial areas was reduced by two- thirds from 7.3km to 2.4km. 93% of Kit Yamoyo users mixed ORS correctly, due to appropriate 200ml sachets and the kit’s measuring function. August 2013 After 12 months’ trial of new Kit Yamoyo design & distribution through existing private sector channels. September 2012 Before Kit Yamoyo. Rural, remote areas. Before After Trial results
- 27. The vision
- 29. ORS Reduce number of sachets to 4 This may also enhance adherence to the combined therapy Zinc Produce locally Design the blister pack to enhance adherence to the 10-day regime Blister pack needs no box Soap Produce locally Leaflet Simplify – single fold. Same leaflet for all formats Packaging Remove constraint of fitting in Coca-Cola crate Produce locally Produce re-fill option Incorporating the learning into the scale-up product
- 31. The Kit Yamoyo bag can be used to measure the correct amount of water.
- 33. Kit Yamoyo on supermarket shelves nationwide
- 34. Kit Yamoyo on supermarket shelves nationwide
- 36. Thinking with design in global health Transforming access to diarrhoea treatment with design thinking – the ColaLife story Where we started Value chain thinking The design process The public sector Why design? Our idea 2 4 6 1 3 5
- 37. v2 The public sector format
- 38. Discontinued from Oct-16 Introduced from Oct-15 Introduced from Oct-16 Supplied to MoH from Sep-15 740,000 distributed, 260 lives saved Introduced from Apr-17 Introduced from May-17
- 39. Discontinued from Oct-16 Introduced from Oct-15 Introduced from Oct-16 Supplied to MoH from Sep-15 68,629 25,123 48,103 592,050 Total 739,724 740,000 distributed, 260 lives saved Introduced from Apr-17 5,819 Discontinued from May-17 80%1%7%3%9%
- 41. Thank you to our supporters past and present Isenberg Family Charitable Foundation Norr USAID DISCOVER-HealthLive Well
Editor's Notes
- When I was invited to speak at this conference I was absolutely delighted. I am a bit of a geek when it comes to product design for health. I’m an accidental designer and have somehow found myself working in the health sector. My organisation, ColaLife which has just two members of staff, is one of the few to have health products in the permanent collections of both the V&A and The Design Museum. Our relationship with the RSM goes back to 2011 when we were spotted by Paul Summerfield who took a risk on us and gave me a platform to speak about our plans at one of the RSM Innovations Briefings. This helped enormously with our credibility which we desperately needed at the time. I’ve reported back to the RSM a couple of times since then at the Innovations conferences but this is the first time I’ve focussed specifically on the design aspects of our work.
- I’ve split my presentation into six sections. The first four are very short but set the context for section 5.
- Design is a fundamental of every aspect of our lives and health products and services are no exception. My approach is: That it is better to design on the basis of what you know people WANT rather than on what you think they NEED. As health professionals you might want to reflect on the extent to which this happens in the health sector. As an outsider looking in, it appears to me that many health products and services are designed by experts on the basis of what they think people need not on what they know they want. Perhaps we can pick this up in the discussion afterwards. This presentation draws on the experience in Zambia which sought to make a diarrhoea treatment kit – Kit Yamoyo – as ubiquitous as Coca-Cola and the crucial role of design in achieving this.
- In 1985 I lived and worked in NE Zambia as a frontline development professional. Outside of my professional world, I was shocked at the level of child mortality. In Africa at that time 1 in 5 children died before their fifth birthday. In 2017 it had fallen to one in 13 or 7.4% - still alarmingly high. And eight times higher than the mortality rate here in Europe.
- Just as shocking as this level of mortality is the fact that diarrhoea, an easily treated condition, was the second biggest killer and it still is today. Dehydration from diarrhoea kills as many children as Malaria and HIV/AIDS combined.
- But it is not just about mortality. In sub-Saharan Africa 40% of children are stunted which means they are smaller than they should be for their age. Diarrhoea is a key factor in stunting. If a child is stunted at the age of 2 there will be permanent effects on both physical and mental development. They will never reach their full potential.
- Although diarrhoea is easily treatable with very simple medicines people don’t have easy access to them. The globally recommended treatment for Diarrhoea is: ORS and Zinc The recommendation is nearly 15 years old but more than 90% of cases are not treated with it. Both ORS and Zinc are simple to manufacture, cheap and stable at ambient temperatures.
- The other thing I observed back in 1985 was, that even in this sparsely populated area, where slash and burn agriculture was a sustainable practice, I could get a Coca-Cola virtually anywhere I went.
- So this question arose. How is it that you can get Coca-Cola anywhere in the world but you can't get life-saving medicines?
- So, working with my wife, we came up with this idea. Putting diarrhoea treatment kits in Coca-Cola crates. The logic was simple. Coke gets everywhere so if the treatment was in the same crates that would get there too. This image resonated with people and went viral. We were featured on BBC Radio 4’s iPM programme and through this were linked up to the right person in Coca-Cola to talk to about this idea. In 2011 we raised the money to test the idea in Zambia.
- We were heavily and publicly criticised for daring to engage with Coca-Cola on a health initiative. But our view was, that we were not going to ignore a bunch of very clever people who could distribute items reliably to all corners of the planet, just because they worked for Coca-Cola. This was expertise that was desperately needed in the health sector and could potentially save hundreds of thousands of young lives. Our engagement with Coca-Cola was at the top level and was well informed. At this point Coca-Cola already had a partnership with WWF which probably don’t know about. They were, and never have been, interested in publicity around their engagement in our work but instead provided us with invaluable advice about how their distribution system works. During the planning phase for our ‘medicines in coke crates’ trial we would have regular telephone meetings with the people at Coca-Cola. A theme of these meetings was us confirming that they were OK with us putting medicines in their crates and them coming back with: “Yes, but what’s the value chain?”. At this point we had no idea what a value chain was, so we looked it up. This is how value chains work. They start with the customer. You must have a product or service that customers value in order to establish a value chain. You establish value by having a desirable product and through awareness raising and promotion. This value translates into demand for the product and this is felt by the local retailer and through the retailer to the wholesaler and so on right up to the manufacturer. Every player in the chain adds value by either making the product, storing it or bringing closer to the customer. The key thing to note is that the system is a ‘pull’ system. The demand from customers pulls the product to them. This explains why, when you go to a remote community you will find Coca-Cola but you will never see a Coca-Cola truck. They don’t take it there. They do not push their product out. Instead, local retailers go and collect in and bring it to the community because of the demand for the product in the community and the profit they can make selling it.
- There are key dependencies involved here. Distribution excellence comes from a strong value chain which in turn requires a desirable, aspirational product…
- … and desirable, aspirational products are the result of good product design.
- So how did we go about designing our diarrhoea treatment kit? The process started here. We spoke to eight groups of caregivers about the challenges they faced treating diarrhoea in the home and we learnt so much. Firstly, litre sachets of ORS are too big for use in the home. ORS comes as a powder that needs to be mixed with safe water. Once mixed up it should be used as soon as possible and any solution still left after 24 hours needs to be thrown away as it gets contaminated. But a child will only drink about 400ml in 24 hours. So if you follow the instructions correctly you will throw away more ORS than you give to your child. Litre sachets of ORS were never designed for the home treatment of diarrhoea. They were designed for use in institutions – hospitals and clinics.. If you have five children lined up with diarrhoea it makes sense to make up ORS by the litre. The situation in the home where you are treating just one child is completely different and a litre is too much to mix up at one time. Measuring water is also a problem, in our trial only 60% of caregivers got this right. Caregivers in resource-poor settings rarely have a litre measure and most will not know what a litre is. == These focus groups also gave us an indication of what caregivers would be prepared to pay for a diarrhoea treatment kit and the caregivers gave us their views on various naming and branding options.
- This is the resulting product – Kit Yamoyo – is:
- • attractive – aspirational even
- • it contains 200ml sachets of ORS
- • the packaging acts as a measure for the water
- • it’s also a mixing device for the ORS
- • and can be used as a cup As well as ORS, the kit contained Zinc supplements and so delivered the 12 year old international standard for diarrhoea treatment: ORS combined with Zinc. The kit also contained soap to help ensure handwashing.
- With the product designed we went into the trial. The trial lasted 12 months and the results were impressive. From a standing start, in 12 months, more that 26,000 kits were bought by retailers serving these communities. Our baseline showed that ORS or Zinc was not available through the private sector before we started. Treatment rates with ORS and Zinc rose from virtually zero to 45%. We reduced caregivers’ need to travel to access ORS by two thirds; from 7.3km to 2.4km because ORS and Zinc was available in community shops which are more numerous and therefore closer to people’s homes. And finally, we increased the accuracy with which caregivers mixed the ORS due to the measuring functionality built into the packaging.
- However, our idea of transporting kits in crates did not work. What we thought was THE innovation was not the innovation at all. Less than 4% of retailers put the kits in Coca-Cola crates.
- In practice, this is what happened. Retailers strapped kit Yamoyo to the back of their bicycle along with everything else. It wasn’t the space in the crates that was important, it was the space in the market for a well-designed diarrhoea treatment kit. We had designed and marketed an aspirational product (just like Coke) which people wanted and which retailers could make a profit on by bringing it to their communities to sell (just like Coke).
- At the end of the trial we ploughed all the learning into a re-design of Kit Yamoyo. This was aimed at improving the kit but we also had to drive out all subsidy. Nothing was exempt from this review. We even redesigned the much acclaimed packaging that fitted between the Coke bottles in a crate. Nothing was sacred!
- The result was two new formats: the screw-top and the flexi-pack Both of these maintained as many of the features as possible from the original design. [Screw-top demo]
- In particular, the water measuring feature.
- We were even able to achieve this with the flexi-pack
- These now sit on supermarket shelves nationwide….
- …. and in hundreds of small community shops
- In 2013, Kit Yamoyo won ‘Product Design of the Year’ beating the latest Nike Trainers, a cool pair of wireless Bang & Olufsen speakers and the Olympic Cauldron. As I said before, all formats are in the permanent collections of both the V&A and the UK’s Design Museum.
- Our focus was on the private sector – making diarrhoea treatment a ubiquitous as Coke. However, since scaling up nationwide in the private sector in Zambia, Zambia’s Ministry of Health have added co-packaged ORS and zinc to the Zambia Essential Medicines List and are procuring a government-branded Kit Yamoyo which given for free at Government health centres. The government version carries government branding but in all other aspects is identical to the flexi-pack available commercially.
- Finally, I wanted to give you a picture of the scale of what we have achieved. The design iterations that I have described have produced five products formats since the start of the trial in Sep-12. These have resulted from design iterations in response to evidence from our trial and feedback from users. Two formats have been discontinued leaving three in production – two for the private sector and one for the public sector.
- Since the beginning of the trial in Sep-12 740,000 kits have left the factory in Lusaka. A conservative estimate is that these will have saved 260 lives and improved many more. Our focus has been on the development of a commercial product. However, this has meant that for the first time a local product is also available to the government. As you can see, the government version is the one that provides the majority of treatments by an order of magnitude. Government engagement is crucial to getting decent coverage rates.
- We withdrew from Zambia earlier this year leaving a commercial product being manufactured locally for the local market. It’s on supermarkets nationwide and in hundreds of small shops and the government is now buying it for distribution through health centres. We believe this to be an example of self-sustaining development – a development that is out-living the donor resources that helped create it.
- None of this would have been possible without the support of many organisations and individuals. Thank you very much.