Narrative Text for a project on Maternal Mortality – (Text from ARC Discovery Submission 2012)
This project is based upon the proposition that current practice of service design fails when used to develop services for poor and marginalized communities. Service design is currently centered around urban and affluent contexts. I wish to expand the practice of service design to take into account services for the rural poor. My case study is maternal health in India.
Current global practices in service design use a mix of methods added on to conventional system design practices (Manzini, Vezzoli et al. 2001; Morelli 2002). These new tools and methods are in the main drawn from contemporary software development practices in the field of interaction design(Manzini January 2009). By becoming significantly integrated into retail business practice discourses, service design has had a significant and visible impact upon society (Cottam and Leadbeater 2004). The goal of this form of design is to improve ‘ease’ of customers’ access to services, improvement of ‘customer experience’ by the innovative use of internet and telecommunications infrastructure that is common in urban contexts (Hollins and Hollins 1991; Varadarajan 2009). This project is based upon the proposition that current practice of service design fails when used to develop services for poor and marginalized communities(Varadarajan and Fennessy 2007). Further arguing that:
- Emerging service design theory is intimately bound by service design practice and
- A project of re-conceptualization cannot be a theoretical discussion of service design and needs to have a case study to underpin the theory development.
Service Design projects in health service delivery have validated inclusive practices such as ‘co-creation’, through examples such as the RED project of the Design Council UK (Cottam and Leadbeater 2004). RED and other milestone projects in service design have been urban projects. The rural poor have not been the subject of a case study thus the practice, and theory, of service design has had little impact beyond the urban(Varadarajan 2009). Elsewhere within conventional service delivery, the preamble to the Indian National Rural Health Mission document amplifies the need to focus upon the rural and mentions the need for an ‘architectural correction’ of the health care services in India(Bajpai, Sachs et al. October 2009). The problem of government health service provision in India being focussed upon urban populations has meant that health indicators for rural populations have been consistently poor and this is manifested in the high incidence of maternal deaths(Padmanaban, Sankara Raman et al. April 2009). Maternal deaths, considered a key indicator for the development status of communities and of the quality of health care services and medical infrastructure of a country, are among the highest in India. With four more years to the 2015 Millennium Development Goals it is expected that the project of maternal mortality reduction would continue to be a location for intense scrutiny of service delivery(Mavalankar, Vora et al. April 2008). This sets up a location for a case study and lends urgency to a peripheral discourse in mainstream design practice, that of services for the poor and rural.
I commenced work on this case study in late 2009. This was a pilot project supported with seed funding from the Design Research Institute at RMIT to trial the project and methodology on a small scale. The research in the pilot project began with a literature review, a mapping of the stakeholder network followed by a field-study phase. The field-study was undertaken in two stages; the first being interviews with key agencies that were either doing research on maternal health or were actively involved in projects at the grass roots level. The second stage was interviews in one specific location, the state of Assam in India, with rural families and key stakeholders in the maternal health system in Assam. The information gleaned from the analysis of the interviews was compared with what I was reading in the literature. The outcome was the formulation of a theoretical strategy as themes for engagement, similar to a set of design concerns that contained both universal elements that applied to other contexts and specific elements that were particular to the local context I had studied. The pilot project concluded that services for marginalized and remote communities are indeed a separate category of services. A methodology of service design practice in such contexts would need to be; one, inclusive and account for traditions and deep rooted community practices; and two, decentralized, to account for both the need to support and stimulate local economy and to build self reliance as a way to tackle potential marginalizations(Gupta 2007). In effect such a practice of service design would do well to be situated in opposition to mainstream service design practice that privileges centralization, use of sophisticated technologies and assumes urban consumption practices. This preliminary hypothesis of ‘service design for the unserved’ was written up and presented at a conference in Assam (Addressing Maternal Mortality in Assam, Dec 2010) and at a public lecture (Bangalore, Jan. 2011).
The project fills a major gap in the theory of service design. Service design theory has evolved with a focus upon privileging expert discourses in a predominantly urban context (Shostack 1982; Normann 2000; Leadbeater and Cottam 2008) This form of practice is focused upon redesigning existing services to either reduce cost, or improve customer experience and is predominantly targeted at urban, educated and affluent consumers of services(Glaeser, Kolko et al. 2001; Frug April, 1998). In instances where projects in health care services have been visualized the significant beneficiary is the client often the publicly owned service(Cottam and Leadbeater 2004). Extending such a paradigm of practice carries the danger of producer side thinking into disadvantaged communities and often the situation turns exploitative(Whitehead, Dahlgren et al. 2001; Wagstaff 2002; Goodman Jan 1968). The current project fills the gap by proposing an inclusive approach; where health indicators take precedence over economics; where people are central beneficiaries and where marginalized communities are supported to become self reliant and responsible for their quality of life outcomes(Yunus and Jolis 1999). This project offers a contribution to a long-standing debate on user side thinking in service design theory.
The project makes a major contribution to current service provisions targeted at rural, remote and tribal communities. Access to service in regional communities, communities distant from economic hubs, is a crucial problem in India. For tribal communities this shows up as a life expectancy gap between urban and regional populations. The conventional approach has been to push services and infrastructure designed for urban population concentrations into regional areas, followed by education to get compliance on proper usage. This project is significant because it opens up a theoretical promise of amplifying notions of alternative forms of development and realizing valuable goals through innovative inclusive designs of services. An inclusive model of service design will impact upon aspects other than just maternal health. In this way the project offers a major contribution to the long standing debate about approaches in service delivery for poor and marginalized people(Wearing).
The project is thematically innovative as it extends a service design research framework to apply to marginalized communities. To do this the project eliminates the commercial client and sets up a research project along the lines of a large action research service design project(Soumitri and Chaudhuri 2001). Such a transformation is crucial for the reformulation of practice as historically service design has evolved from an interest in the design of user experiences. While user experience design is about improving the quality of the event when individuals interact with a service the practice has in the main been about a better design of the graphical user interface (GUI) and about the potential for tangible interfaces in allowing for alternative modes of interacting with service delivery points(Bruseberg and McDonagh-Philp 2001). While service design theory itself has two main themes, that of affordances and technologies of interaction and of increasing ease of access to services, historically a greater focus upon technology has suppressed the discourse of access(Candi 2007). The project design in setting up a problem location where access is restored as a central theme amplifies two key agendas in design discourse: a political agenda, focus upon marginalized communities, and a theoretical agenda, deriving a new model of service design practice.
The project is innovative in its method as it locates the field study in a remote rural context thereby challenging contemporary design ethnography practices. By its choice of location of field work the project changes the form of ethnography that is to be conducted to inform the project. Design ethnography in the service of a client project (Segelström, Raijmakers et al. 2009) is often strategic in its intent and privileges the clients’ intentions at the cost of the genuine needs of the community. Additionally the practice of design ethnography accepts small and sporadic events of immersion, privileging thereby certain categories of information that would be useful for design. A deep and prolonged field study, as has been visualized for this project, suspends judgment till after the research field-study has been completed. The theoretical implication of working in rural, rather than urban areas, therefore has the potential to change the nature of inquiry and the outcomes of research. Further focussing upon just the rural poor allows service design thinking then not to be only about technology, such as internet enabled delivery of services.
The project is conceptually innovative as it keeps the issue of ownership open and unresolved by problematizing the client-designer duopoly as a necessary relationship in the formulation of service design solutions. The removal of a commercial client opens up the potential for service provision, potentially by governments, to be owned in three discrete ways; by community, by service provider and jointly owned by service provider and community, which then mirrors emerges approaches to governance (ref pluralism). In fact approaches to sustainbility outcomes would assume collaborative ownership and community oversight leads to better outcomes(ref). The conceptual framework thus sets up a problem, the theoretical implications of which can be tested in the case study of maternal health for remote poor communities.
Approach And Method
There are two significant phenomena relevant to the current application. One, is a situation of heightened awareness in the Australia to issues of social engagement and service design, where both universities and government agencies have watched events unfold in the United Kingdom’s House of Commons debates and transformation of public services (2008). There is in fact an emerging openness to propositions of service design within local, Australian and Victorian, service delivery practices(Dawes 2009). Two, is a unique situation of rethink and reformulation of rural health services underway in India brought on by its commitment to meet the Millennium Development Goals(Mavalankar, Vora et al. April 2008). This commitment has created a condition of unprecedented openness to innovation among government agencies dealing with rural health. Together the two situations create a space and a need for a robust case study on service design for rural and remote delivery.
The theoretical context of service design for the unserved is set out here. Service design for poor, hence marginalized communities, is a unique field characterized by neglect and poor performance of public services(Sainath 1992; Louis 2007; Mavalankar, Vora et al. April 2009). 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 remote and 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 Jun-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 design thinking 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 Jul-Sep 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 becomes illegal(Jeffery, Jeffery et al. 1984 Jul-Sep; 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’ (ref).
The project field work has been deliberately located in a place, the river islands of Brahmaputra in Assam, where the state has failed to and will not provide services(Hazarika 2003) and instead expects the non-governmental sector to be the service provider. While this is a situation that satisfies the current goal of universal coverage of health care the long term prospects of such avoidance of service provision come unstuck especially when seen in the framework of the charter of ‘rights’(ref). The theoretical underpinnings of this inquiry have two components that are crucial; one, is a field study (Wasson 2000; Sanders 2008) to observe and study maternal health in the community and two, will be the definition of the network of actors (Callon, Law et al. 1986; Akrich and Latour 1992; Law and Mol June, 2004) to reconstruct the condition in abstraction. It is the discourse of the actors that will constitute the description of the maternal health condition in the char areas of Assam. The project approach is therefore an inquiry in the reconceptualizing of service design for the unserved that has an agenda of inclusivity(Smith and Fischbacher 2005; Varadarajan, Fennessy et al. 2007; Adler and Kwon January 2002) encompassing the key themes of distance(Tudor Hart 1971; Young 2006), “provider pluralism”, and self reliance.
The method for the project contains three key aspects: an extended field study, a stage of exploring practice that involves reconceptualizing practice by undertaking research through design and a synthesis of the research findings into a specific framework for service design.
Stage 1 – Field Study
The first activity is one of planning the project: this will include recruiting the research assistant (RA) through a limited advertisement and organizing the field trip. Ethics approval will be sought prior to the field study with the submission of the questionnaire and a statement of methodology describing the photography and video recordings that will be done. The ethics clearance is expected to be a more than moderate risk level due to interviews of affected families. On completion of planning and getting the ethics approval I will undertake two field-study trips, of three months each, separated by a gap of about three months to avoid the monsoon season in India. The field study will be undertaken in the river islands of the Brahmaputra, the Char areas of Assam state, where health services for the population are being organized by an NGO, Centre for North East Studies (CNES), and delivered by boat(Hazarika 2010). The field study will involve interviews of three stakeholder groups; the rural remote community, the government health service NRHM staff and the non government organizations (NGOs) working in the community. The community interviews will use a modified version of the ‘verbal autopsy'(Soleman, Chandramohan et al. 2006) to investigate the circumstances surrounding the maternal death in the community (interviews structured like a verbal autopsy were used in the pilot project). The event of the community interview would be photographed to establish the context for design visualizations. The interviews with the government staff and NGOs will be recorded both in audio and video format.
The field study will generate two kinds of raw data – one will be the questionnaire data and interview recordings and the other will be the information from participant observation, video and still photography. This data will be analysed though year 2. The analysis will produce a theoretical account of the condition of maternal health in a remote community.
Stage 2 – Exploring Practice
The field study and analysis will be followed by the activity of ‘research through design’ (quote Cross- and designerly ways of knowing, and Peter Downton – PD in group of experts) which will comprise the two activities of Modelling, and Testing.
- Modelling: The activity of modeling will use the sociology of technology framework of actor network theory (which I used in my PhD and in the Diabetes research) to develop a graphical model of actors, and a narrative of the agency contained in each of the actors. This is a variant of the analytical activity undertaken as part of ‘design ethnography’ (Sanders 2008). The key outcome of this stage is a complex portrayal of the system studied in the field.
- Testing: The abstract model will be tested in two stages:
- Testing Stage 1 – Backcasting and Action Planning: The first stage of testing will involve the use of Vergragt’s (Vergragt 2001) methodology of reconciling future goals with the model of a current condition. The outcome of this activity is both a road map, referred to as action planning, and a map of lesser goals which can be set up as targets. These outcomes are tested through a process of review by a panel of ‘subject experts’ (the subject experts are detailed in the ‘role of personnel’ section of this application). The backcasting activity will produce a set of graphical and outcomes that can be taken forward to further testing in the field.
- Testing Stage 2 – Service Design CoCreation: The activity of testing outcomes in the field will be undertaken in year 2 and 3. It will involve testing the outcomes of Action Planning by engaging in Co-Creation with the stakeholders in Assam. This will follow; one, the methodology of community engaged practiced by Cottam (Cottam and Leadbeater 2004) in the RED project, and two; the framework of participatory planning advocated by Chambers (Chambers 1997). The activity of co-creation will focus on two clear community goals for service delivery that were defined through the pilot project: that of ‘safe motherhood’ (SM) and that of ‘emergency obsteteric care’ (EmOC). CI Varadarajan will conduct the co-creation sessions in the community.
Stage 3 – Articulating the Service Design Framework
While the two notions of social design (Margolin and Margolin 2002) and inclusive design(Goodman, Langdon et al. 2006) provide the basis for the construction of the theoretical framework, the goal in this research project will be to: one, establish a specific category of practice that privileges the theoretical discourse set out in the approach and two, set out a theoretical framework for research and practice in service design.
The project sets out to offer a novel approach to service design by focusing upon a case study of an unserved populations (view service provision from the perspective of remote communities) for purposes of developing new process models and guidelines and new results (theoretical frameworks) for the benefit of service users. While the project uses established processes in design research – the artefact outcomes that will be privileged by the way the project is constructed will be different. It is in this context that the following outcomes are visualized. Outcomes that have the potential in this emerging field to become widely disseminated and adopted within an ongoing program of work within the field of Service Design theory and the development of Service Design practice.
- An analytical articulation on current practices in service design showing their urban-context embeddedness.
- A service design thesis of practice that separates technological affordances from service design.
- The first service design research project informed by deep case study grounded in an off the grid context.
- New ways of constructing goals, new methods of community engaged service creation.
- Improved procedures and techniques in designing and in managing design.
- The findings will be published in a book form.
The project would contribute a valuable case study to convince [Australian?] governments of the value of service design. While case studies of improvements in specific sectors of service delivery in Europe have had an impact upon government thinking in Australia, service delivery Australia presents a unique geographic challenge for service designers. Contemporary service design practice, with its combination of communication and interaction design, is almost completely focussed upon urban internet users and the profits of service providers relies on heavy urban concentrations of consumers. While a combination of social innovation and service design is emerging as a practice in pockets in Australia, the focus is still urban. In effect the problem of few urban concentrations, situated amidst a sparsely populated but vast regional landmass, confounds existing capabilities in service design discourse. The project thus picks up a marginal theme in mainstream service design discourse, the focus upon distant and potentially poor regional populations, and amplifies it as a key theme for inquiry. The project has therefore the potential to present new approaches and methods for service design for regional contexts, which can impact upon the social and economic fabric of disadvantaged populations.