Service provision for rural poor is a unique field characterized by neglect and poor performance of public services (Sainath 1992; Louis 2007). Approaches to the poor and marginalized in design have been characterized by a discourse of social engagement and social entrepreneurship (Jegou and Manzini 2008). While a focus upon the rural poor (Papanek 1985) has found form as the practice of social design (Margolin and Margolin 2002) with a strong focus upon artifacts (Rawsthorn 2007) the main paradigm is still one of pushing from the centre to the periphery (Er 2001). Interestingly if we were to pick up the counter current of documenting practices of the poor or old and traditional (Gennep, Vizedom et al. 1960; Varadarajan 2009) and amplify the essential paradigm that characterizes them we see similarities with social design projects in their approach of focussing upon self reliance. Service provision in health, universally viewed as a state subject has two key problems; one is the focus upon increasing access to and compliance with state services in remote areas (Humphery, Weeramanthri et al. 2001) and two is that “provider pluralism”, where different forms of service providers are allowed to operate, often goes unrecognized and is marginalized in state plans (2005). Provider pluralism (Chernichovsky 2002; Sheehan 2009), actively encouraged in urban areas is mirrored by self reliance in remote areas. With more regulation in rural contexts such pluralism often gets ‘written out’ and even competent local health practitioners could have their work rendered illegal (Jeffery, Jeffery et al. 1984; Ram 2001).
To summarise, service provision for the rural poor is a complex context for design which demands that service design theory needs to move beyond: one, the urban context and reliance on infrastructure to become more widely applicable, and two, privileging the client’s needs and ‘work creatively with messy and sometimes contradictory realities to achieve better outcomes’ (Standing and Bloom 2002).